Basic Information
| Provider Information | |||||||||
| NPI: | 1366827396 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELERSON | ||||||||
| FirstName: | KENNETH | ||||||||
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| Credential: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 PREMIER DR | ||||||||
| Address2: | STE 234 | ||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750632661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727561222 | ||||||||
| FaxNumber: | 8172492215 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 PREMIER DR | ||||||||
| Address2: | STE 234 | ||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750632661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727561222 | ||||||||
| FaxNumber: | 8172492215 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2015 | ||||||||
| LastUpdateDate: | 07/20/2015 | ||||||||
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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 | 103K00000X | 1-15-18179 | TX | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.