Provider Demographics
NPI:1700524238
Name:ELLIOTT, AUDREY
Entity type:Individual
Prefix:
First Name:AUDREY
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 1:75 WINTER VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-4861
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:216 W SAND BANK RD STE 14
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-1084
Practice Address - Country:US
Practice Address - Phone:618-281-2307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker