Provider Demographics
NPI:1366587016
Name:PRIDDY, ELTON MICHAEL (LCPC)
Entity type:Individual
Prefix:MR
First Name:ELTON
Middle Name:MICHAEL
Last Name:PRIDDY
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:MR
Other - First Name:E.
Other - Middle Name:MICHAEL
Other - Last Name:PRIDDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCPC
Mailing Address - Street 1:PO BOX 24131
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66283-4131
Mailing Address - Country:US
Mailing Address - Phone:913-449-3696
Mailing Address - Fax:913-548-4816
Practice Address - Street 1:12400 W 62ND TER
Practice Address - Street 2:SUITE G
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66216-1833
Practice Address - Country:US
Practice Address - Phone:913-449-3696
Practice Address - Fax:913-548-4816
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS229101YP2500X
MO2002008095101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional