MEDICARE: JOHNATHAN ELLIOTT

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	101YP2500X	Professional Counselor	70211	TX

General Provider Information

NPI Number	:	1932590502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHNATHAN ELLIOTT

Provider Business Mailing Address
First Line	:	4504 STEAMBOAT SPRINGS DR
Second Line	:
City	:	KILLEEN
State	:	TX
Zip	:	76542-7530
Country	:	US
Telephone Number	:	361-215-3117
Fax Number	:

Provider Business Practice Location Address
First Line	:	4504 STEAMBOAT SPRINGS DR
Second Line	:
City	:	KILLEEN
State	:	TX
Zip	:	76542-7530
Country	:	US
Telephone Number	:	361-215-3117
Fax Number	:

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

Provider Enumeration Date	:	02/18/2015
Last Update Date	:	02/18/2015

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Directions to “ JOHNATHAN ELLIOTT ” Practice Location

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