Basic Information
| Provider Information | |||||||||
| NPI: | 1669431466 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELLIOT PROFESSIONAL SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ELLIOT BEHAVIORAL HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 445 CYPRESS ST STE 8 | ||||||||
| Address2: | ELLIOT BEHAVIORAL HEALTH SERVICES | ||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031033600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036684079 | ||||||||
| FaxNumber: | 6036638605 | ||||||||
| Practice Location | |||||||||
| Address1: | 445 CYPRESS ST STE 8 | ||||||||
| Address2: | ELLIOT BEHAVIORAL HEALTH SERVICES | ||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031033600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036684079 | ||||||||
| FaxNumber: | 6036638605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 06/20/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HERMAN | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS & FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6036634904 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ELLIOT PROFESSIONAL SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 30212259 | 05 | NH | MEDICAID | CK3360 | 01 | NH | RR MEDICARE GRP PIN | OTHER |