Provider Demographics
NPI:1609606474
Name:ELLIOTT, ANDIA XZURY
Entity type:Individual
Prefix:
First Name:ANDIA
Middle Name:XZURY
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 1:1500 LIGHT RD APT 208
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-9333
Mailing Address - Country:US
Mailing Address - Phone:331-203-8524
Mailing Address - Fax:
Practice Address - Street 1:1500 LIGHT RD APT 208
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-9333
Practice Address - Country:US
Practice Address - Phone:331-203-8524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist