Provider Demographics
NPI:1043663164
Name:ELLIOTT, ALICE
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40203-1799
Mailing Address - Country:US
Mailing Address - Phone:502-583-1011
Mailing Address - Fax:855-859-0123
Practice Address - Street 1:300 S 13TH ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-1799
Practice Address - Country:US
Practice Address - Phone:502-583-1011
Practice Address - Fax:855-859-0123
Is Sole Proprietor?:No
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY168488225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist