Healthcare Provider Details

I. General information

NPI: 1689725574
Provider Name (Legal Business Name): ROBERT WILLIAM ELLIOTT PSYCHOLOGIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 03/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5777 W CENTURY BLVD STE 1645B
LOS ANGELES CA
90045-5696
US

IV. Provider business mailing address

5777 W CENTURY BLVD STE 1645B
LOS ANGELES CA
90045-5696
US

V. Phone/Fax

Practice location:
  • Phone: 310-545-6400
  • Fax: 310-939-7065
Mailing address:
  • Phone: 310-545-6400
  • Fax: 310-939-7065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY5107
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number711
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: