Provider Demographics
NPI:1306451877
Name:ASSANAH, ELIJAH DAVID CHRISTOPHER
Entity type:Individual
Prefix:
First Name:ELIJAH
Middle Name:DAVID CHRISTOPHER
Last Name:ASSANAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 TORRINGTON DR
Mailing Address - Street 2:
Mailing Address - City:MASCOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:34753-9538
Mailing Address - Country:US
Mailing Address - Phone:321-947-7152
Mailing Address - Fax:
Practice Address - Street 1:1820 ARMSTRONG BLVD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-2589
Practice Address - Country:US
Practice Address - Phone:407-559-4854
Practice Address - Fax:321-332-7799
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician