Healthcare Provider Details

I. General information

NPI: 1477483774
Provider Name (Legal Business Name): ELLIOTT BRYANT UNDERWOOD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1274 CENTER COURT DRIVE SUITE 211 COVINA CA 91724
COVINA CA
91724
US

IV. Provider business mailing address

1274 CENTER COURT DRIVE SUITE 211 COVINA CA 91724
COVINA CA
91724
US

V. Phone/Fax

Practice location:
  • Phone: 626-339-4999
  • Fax:
Mailing address:
  • Phone: 626-339-4999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: