Basic Information
Provider Information | |||||||||
NPI: | 1033140306 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ELDER | ||||||||
FirstName: | WILLIAM | ||||||||
MiddleName: | GIBBS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4349 MARTIN LUTHER KING BLVD HEALTH 2 BLDG SUITE 1001E | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 772040001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7137439682 | ||||||||
FaxNumber: | 7137431049 | ||||||||
Practice Location | |||||||||
Address1: | 4349 MARTIN LUTHER KING BLVD HEALTH 2 BLDG SUITE 1001E | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 772042043 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7137439682 | ||||||||
FaxNumber: | 7137431049 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2006 | ||||||||
LastUpdateDate: | 07/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/28/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 1108 | KY | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 38344 | TX | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
ID | Type | State | Issuer | Description | 89011084 | 05 | KY |   | MEDICAID |