MEDICARE: LISA M ELLIOTT PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	25244	TX
2	103TC2200X	Clinical Child & Adolescent Psychologist	25244	TX

General Provider Information

NPI Number	:	1093890139
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA M ELLIOTT PHD

Provider Business Mailing Address
First Line	:	PO BOX 99213
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76199-0213
Country	:	US
Telephone Number	:	682-885-4871
Fax Number	:	682-885-3939

Provider Business Practice Location Address
First Line	:	3201 TEASLEY LN
Second Line	:	STE 202
City	:	DENTON
State	:	TX
Zip	:	76210-8302
Country	:	US
Telephone Number	:	940-484-4311
Fax Number	:	940-484-5075

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	04/09/2021

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Directions to “ LISA M ELLIOTT PHD” Practice Location

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