Healthcare Provider Details

I. General information

NPI: 1417009937
Provider Name (Legal Business Name): STEPHEN SEALS ELLIOTT PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 01/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3205 RANDALL PKWY STE 105
WILMINGTON NC
28403-2565
US

IV. Provider business mailing address

PO BOX 538622
ATLANTA GA
30353-8622
US

V. Phone/Fax

Practice location:
  • Phone: 910-742-9243
  • Fax: 888-746-1787
Mailing address:
  • Phone: 910-742-9243
  • Fax: 888-746-1787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1010
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number1010
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number283
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: