MEDICARE: ELITE EDUCATIONAL AND THERAPEUTIC SUPPORT SERVICES

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	103TS0200X	School Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LEP3615	OTHER	CA	EDUCATIONAL PSYCHOLOGY

General Provider Information

NPI Number	:	1891384038
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE EDUCATIONAL AND THERAPEUTIC SUPPORT SERVICES

Provider Business Mailing Address
First Line	:	155 COLUMBIA ST
Second Line	:
City	:	DURYEA
State	:	PA
Zip	:	18642-1403
Country	:	US
Telephone Number	:	570-466-5870
Fax Number	:

Provider Business Practice Location Address
First Line	:	17946 CONTADOR DR
Second Line	:
City	:	ROWLAND HEIGHTS
State	:	CA
Zip	:	91748-4328
Country	:	US
Telephone Number	:	570-466-5870
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. RICHARD A SHILLABEER
Credential	:	PSY.D.
Telephone Number	:	570-466-5870

Provider Enumeration Date	:	01/12/2021
Last Update Date	:	01/12/2021

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