Provider Demographics
NPI:1992081103
Name:ELLIOTT, JAMES RANDOLPH (LCSW)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:RANDOLPH
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:NA
Other - Middle Name:NA
Other - Last Name:NA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NA
Mailing Address - Street 1:615 BRIARWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3608
Mailing Address - Country:US
Mailing Address - Phone:909-305-6978
Mailing Address - Fax:
Practice Address - Street 1:615 BRIARWOOD LN
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3608
Practice Address - Country:US
Practice Address - Phone:909-305-6978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA254851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical