Basic Information
| Provider Information | |||||||||
| NPI: | 1104939503 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | GLEN | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D., M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 650 CLARK WAY | ||||||||
| Address2: | |||||||||
| City: | PALO ALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 943042300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6506883649 | ||||||||
| FaxNumber: | 6506883669 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 CLARK WAY | ||||||||
| Address2: | |||||||||
| City: | PALO ALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 943042300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6506883649 | ||||||||
| FaxNumber: | 6506883669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 11/10/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | G44741 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | G44741 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 00G447410 | 05 | CA | MEDICAID |