1891060869 NPI number — MR. PETER ROSS ELLIOTT LMSW, CAADC, CCS

Table of content: MR. PETER ROSS ELLIOTT LMSW, CAADC, CCS (NPI 1891060869)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891060869 NPI number — MR. PETER ROSS ELLIOTT LMSW, CAADC, CCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIOTT
Provider First Name:
PETER
Provider Middle Name:
ROSS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LMSW, CAADC, CCS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891060869
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 BENJAMIN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YPSILANTI
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48198-3094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-483-1718
Provider Business Mailing Address Fax Number:
313-346-3600

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15380 MONICA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48238-1942
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-345-3600
Provider Business Practice Location Address Fax Number:
313-345-1586
Provider Enumeration Date:
03/09/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6801046721 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: C-00023 . This is a "MICHIGAN CERTIFICATION BOARD FOR ADDICTION PROFESSIONALS - CAADC" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 6801046721 . This is a "DEPARTMENT OF COMMUNITY HEALTH BOARD OF SOCIAL WORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: C-J0012 . This is a "MICHIGANB CERTIFICATION BOARD FOR ADDICTION PROFESSIONALS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: S-00013 . This is a "MICHIGAN CERTIFICATION BOARD FOR ADDICTION PROFESSIONALS - CCS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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