Provider Demographics
NPI:1174223549
Name:ELLIOTT, AJA DELAINE
Entity type:Individual
Prefix:MRS
First Name:AJA
Middle Name:DELAINE
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 1:32 MILLBRANCH RD STE 40
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1673
Mailing Address - Country:US
Mailing Address - Phone:601-255-5264
Mailing Address - Fax:
Practice Address - Street 1:32 MILLBRANCH ROAD
Practice Address - Street 2:SUITE 40
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1673
Practice Address - Country:US
Practice Address - Phone:601-255-5264
Practice Address - Fax:866-625-0559
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSRBT-23-259965106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician