Provider Demographics
NPI:1023160397
Name:REID, ELAINE B
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:B
Last Name:REID
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 1:750 CENTRAL AVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-3434
Mailing Address - Country:US
Mailing Address - Phone:603-742-1097
Mailing Address - Fax:603-742-5762
Practice Address - Street 1:750 CENTRAL AVE
Practice Address - Street 2:SUITE G
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-3434
Practice Address - Country:US
Practice Address - Phone:603-742-1097
Practice Address - Fax:603-742-5762
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH213103T00000X
NH043191-23-08363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH80627733Medicaid