Healthcare Provider Details

I. General information

NPI: 1780057299
Provider Name (Legal Business Name): ELLIOTT KETAY M.ED.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2015
Last Update Date: 11/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 W PEMBREY DR
WILMINGTON DE
19803-2008
US

IV. Provider business mailing address

218 W PEMBREY DR
WILMINGTON DE
19803-2008
US

V. Phone/Fax

Practice location:
  • Phone: 302-650-1550
  • Fax:
Mailing address:
  • Phone: 302-650-1550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number80482
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: