Provider Demographics
NPI:1285054601
Name:ELLIOTT, TRACI (MA, LMHC)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5638 PROFESSIONAL CIR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46241-5042
Mailing Address - Country:US
Mailing Address - Phone:317-247-8900
Mailing Address - Fax:317-247-8935
Practice Address - Street 1:5638 PROFESSIONAL CIR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-5042
Practice Address - Country:US
Practice Address - Phone:317-247-8900
Practice Address - Fax:317-247-8935
Is Sole Proprietor?:No
Enumeration Date:2014-04-24
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002664A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health