Basic Information
| Provider Information | |||||||||
| NPI: | 1407975717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | JEROME | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | AMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11235 SUNBURST ST | ||||||||
| Address2: | |||||||||
| City: | LAKE VIEW TERRACE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913426630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183358117 | ||||||||
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| Practice Location | |||||||||
| Address1: | 760 MOUNTAIN VIEW ST | ||||||||
| Address2: | |||||||||
| City: | ALTADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910014925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267986793 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 11/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 122209 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.