Provider Demographics
NPI:1174284632
Name:ELLIOTT, PRESTON MICHAEL (BSW)
Entity Type:Individual
Prefix:
First Name:PRESTON
Middle Name:MICHAEL
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2277 S GROVE ST APT 322
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-9244
Mailing Address - Country:US
Mailing Address - Phone:734-658-2890
Mailing Address - Fax:
Practice Address - Street 1:2277 S GROVE ST APT 322
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-9244
Practice Address - Country:US
Practice Address - Phone:734-658-2890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator