Provider Demographics
NPI:1962894014
Name:ELLIOTT, LAGRAND
Entity type:Individual
Prefix:
First Name:LAGRAND
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:LAGRAND
Other - Middle Name:
Other - Last Name:ELLIOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:107 MEADOW POINTE CV
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-5014
Mailing Address - Country:US
Mailing Address - Phone:601-720-1409
Mailing Address - Fax:
Practice Address - Street 1:107 MEADOW POINTE CV
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-5014
Practice Address - Country:US
Practice Address - Phone:601-720-1409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-26
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency