Basic Information
| Provider Information | |||||||||
| NPI: | 1003014739 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | B | ||||||||
| MiddleName: | L. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9041 | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954051041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075086341 | ||||||||
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| Practice Location | |||||||||
| Address1: | 747 FRONT ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941111945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075086341 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2007 | ||||||||
| LastUpdateDate: | 03/18/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TR0400X | Y | Behavioral Health & Social Service Providers | Psychologist | Rehabilitation |
No ID Information.