MEDICARE: DR. NANCY ANN ELLIOTT PH.D.

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
1	103T00000X	Psychologist	2600-057	WI
2	103TA0400X	Addiction (Substance Use Disorder) Psychologist	2600-057	WI
3	103TC0700X	Clinical Psychologist	2600-057	WI
4	103TC1900X	Counseling Psychologist	2600-057	WI
5	103TF0200X	Forensic Psychologist	2600-057	WI

General Provider Information

NPI Number	:	1568794469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NANCY ANN ELLIOTT PH.D.

Provider Business Mailing Address
First Line	:	712 LOIS DR
Second Line	:	P.O. BOX 146
City	:	SUN PRAIRIE
State	:	WI
Zip	:	53590-1100
Country	:	US
Telephone Number	:	608-213-5474
Fax Number	:	888-643-9220

Provider Business Practice Location Address
First Line	:	712 LOIS DR
Second Line	:
City	:	SUN PRAIRIE
State	:	WI
Zip	:	53590-1100
Country	:	US
Telephone Number	:	608-213-5474
Fax Number	:	888-643-9220

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/03/2010
Last Update Date	:	02/03/2010

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