Provider Demographics
NPI:1780562801
Name:FONGERS, ELLIOT CAILYN
Entity type:Individual
Prefix:
First Name:ELLIOT
Middle Name:CAILYN
Last Name:FONGERS
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 1:1314 W ROBERTS AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-1948
Mailing Address - Country:US
Mailing Address - Phone:765-660-3520
Mailing Address - Fax:
Practice Address - Street 1:2620 ACCUTECH WAY
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-9462
Practice Address - Country:US
Practice Address - Phone:317-674-6592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-26
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-25-466132106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician