Provider Demographics
NPI:1073644373
Name:ELLIOTT, LISA MICHELLE (LICDC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MICHELLE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:LICDC
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:MICHELLE
Other - Last Name:CICERRELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PROFESSIONAL EQUIVLA
Mailing Address - Street 1:305 W 20TH ST
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44052-3726
Mailing Address - Country:US
Mailing Address - Phone:440-989-4971
Mailing Address - Fax:440-246-0189
Practice Address - Street 1:305 W 20TH ST
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44052
Practice Address - Country:US
Practice Address - Phone:409-894-9714
Practice Address - Fax:440-246-0189
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH131144101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)