Mary Jane Elliott, PH.D.

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

3939 Issued in NC

Practice address

3779 Vest Mill Rd
Suite B
Winston Salem, NC 27103-2991

Phone

(336) 768-0919

Fax

(336) 740-9135

NPI assigned

May 1, 2007

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in NC

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Clinical Psychologist

Education

Other, 2000

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Philosophy

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1177977600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1282003200000",
    "number": "1982825865",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3779 VEST MILL RD",
            "address_2": "SUITE B",
            "city": "WINSTON SALEM",
            "state": "NC",
            "postal_code": "271032991",
            "telephone_number": "336-768-0919",
            "fax_number": "336-740-9135"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3779 VEST MILL RD",
            "address_2": "SUITE B",
            "city": "WINSTON SALEM",
            "state": "NC",
            "postal_code": "271032991",
            "telephone_number": "336-768-0919",
            "fax_number": "336-740-9135"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ELLIOTT",
        "first_name": "MARY",
        "middle_name": "JANE",
        "name_prefix": "Dr.",
        "credential": "PH.D.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2007-05-01",
        "last_updated": "2010-08-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "CA",
            "license": "18853",
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "NC",
            "license": "3939",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6001212",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• J Grady Elliott, O.D.
• Kathleen Marilyn Elliott, MD
• Kelly Kaitlin Elliott, DPM
• Larry Eugene Elliott, RPH
• Mary Elliott
• Thomas Scott Elliott, PHARMD
• Wendy Owens Elliott
• Kathleen Ellis-Dowling, MS, CCC-SLP
• Leslie R Ellis, MD
• Matthew Nigel Hugh Ellis, MD

• Clinical Psychologist in Winston Salem, NC
• Providers in Winston Salem, NC by specialty
• Clinical Psychologist in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 17, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.