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NPI Code Detail

MEDICARE: J MAXIE ELLIOTT

MEDICARE: J MAXIE ELLIOTT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103TS0200XSchool PsychologistAZ

General Provider Information

NPI Number : 1487853560
Entity Type Code : Individual
Provider Name (Legal Business Name) : J MAXIE ELLIOTT
Provider Business Mailing Address
First Line : 2200 HAVASUPAI BLVD
Second Line :
City : LAKE HAVASU CITY
State : AZ
Zip : 86403-3122
Country : US
Telephone Number : 928-505-6911
Fax Number :
Provider Business Practice Location Address
First Line : 2200 HAVASUPAI BLVD
Second Line :
City : LAKE HAVASU CITY
State : AZ
Zip : 86403-3122
Country : US
Telephone Number : 928-505-6911
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/17/2007
Last Update Date : 07/25/2007

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