Provider Demographics
NPI:1609902154
Name:ELLIOTT, MARK LYNN (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:LYNN
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4775 KNIGHTSBRIDGE BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-4313
Mailing Address - Country:US
Mailing Address - Phone:614-442-3347
Mailing Address - Fax:614-451-6734
Practice Address - Street 1:4775 KNIGHTSBRIDGE BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-4313
Practice Address - Country:US
Practice Address - Phone:614-442-3347
Practice Address - Fax:614-451-6734
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4210103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical