Healthcare Provider Details

I. General information

NPI: 1114294568
Provider Name (Legal Business Name): ELLIOT ISOM LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2011
Last Update Date: 03/23/2020
Certification Date: 03/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 OAK ST
HAYS KS
67601-3659
US

IV. Provider business mailing address

2013 E 21ST ST UNIT B
HAYS KS
67601-2738
US

V. Phone/Fax

Practice location:
  • Phone: 785-628-3575
  • Fax:
Mailing address:
  • Phone: 785-639-5135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3576
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: