Provider Demographics
NPI:1730249384
Name:ELIAS, CAROL MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:MARIE
Last Name:ELIAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2001 N GAREY AVE
Mailing Address - Street 2:STE. 107
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-2773
Mailing Address - Country:US
Mailing Address - Phone:909-622-0148
Mailing Address - Fax:909-622-7101
Practice Address - Street 1:2001 N GAREY AVE
Practice Address - Street 2:STE. 107
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2773
Practice Address - Country:US
Practice Address - Phone:909-622-0148
Practice Address - Fax:909-622-7101
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 16418103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL 164180OtherBLUE SHIELD
CA1730035OtherFIRST HEALTH
CA208817OtherMANAGED HEALTH NETWORK
CA61-95987OtherUS BEHAVIORAL HEALTH PLAN
CA407529OtherVALUE OPTIONS
CAPSY164180Medicaid
CAPSY164180Medicaid