Basic Information
| Provider Information | |||||||||
| NPI: | 1437496668 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELROD | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | BA, CMII | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 48 | ||||||||
| Address2: | |||||||||
| City: | MEAD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734490048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5807459610 | ||||||||
| FaxNumber: | 5807459650 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 N 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | DURANT | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747013801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809313008 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2013 | ||||||||
| LastUpdateDate: | 06/09/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 100708380 | 05 | OK | MEDICAID | 200049040 | 05 | OK | MEDICAID |