Basic Information
Provider Information | |||||||||
NPI: | 1518239490 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ELBERT | ||||||||
FirstName: | ROSE | ||||||||
MiddleName: | ELIZABETH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HIRT | ||||||||
OtherFirstName: | ROSE | ||||||||
OtherMiddleName: | ELIZABETH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1027 EVERGREEN ST | ||||||||
Address2: |   | ||||||||
City: | FAIRBANKS | ||||||||
State: | AK | ||||||||
PostalCode: | 997094306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 0794518164 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1027 EVERGREEN ST | ||||||||
Address2: |   | ||||||||
City: | FAIRBANKS | ||||||||
State: | AK | ||||||||
PostalCode: | 997094306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9074518164 | ||||||||
FaxNumber: | 9074743621 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/07/2012 | ||||||||
LastUpdateDate: | 03/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/05/2021 |
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 | MH3237 | 05 | AK |   | MEDICAID |