Healthcare Provider Details

I. General information

NPI: 1336611623
Provider Name (Legal Business Name): AMANDA CAROLINE ELLIOTT LSAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2018
Last Update Date: 12/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 W BROADWAY ST
SILVER CITY NM
88061-5353
US

IV. Provider business mailing address

PO BOX 1477
BAYARD NM
88023-1477
US

V. Phone/Fax

Practice location:
  • Phone: 575-654-5568
  • Fax:
Mailing address:
  • Phone: 575-654-5568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCSA0201351
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: