Healthcare Provider Details

I. General information

NPI: 1215664784
Provider Name (Legal Business Name): CODY ELLIOTT RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3361 TEAYS VALLEY RD
HURRICANE WV
25526-9310
US

IV. Provider business mailing address

PO BOX 427
SCOTT DEPOT WV
25560-0427
US

V. Phone/Fax

Practice location:
  • Phone: 681-235-3114
  • Fax: 866-332-2962
Mailing address:
  • Phone: 681-235-3114
  • Fax: 866-332-2962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: