1073644373 NPI number — MRS. LISA MICHELLE ELLIOTT LICDC

Table of content: MRS. LISA MICHELLE ELLIOTT LICDC (NPI 1073644373)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073644373 NPI number — MRS. LISA MICHELLE ELLIOTT LICDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIOTT
Provider First Name:
LISA
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LICDC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CICERRELLA
Provider Other First Name:
LISA
Provider Other Middle Name:
MICHELLE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PROFESSIONAL EQUIVLA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1073644373
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/08/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
305 W 20TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LORAIN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44052-3726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-989-4971
Provider Business Mailing Address Fax Number:
440-246-0189

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
305 W 20TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LORAIN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-894-9714
Provider Business Practice Location Address Fax Number:
440-246-0189
Provider Enumeration Date:
03/08/2007

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: 101YA0400X , with the licence number:  131144 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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