Provider Demographics
NPI:1356010110
Name:ELLIOTT, MARY R (LLMFT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:LLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 289
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-0289
Mailing Address - Country:US
Mailing Address - Phone:517-676-5405
Mailing Address - Fax:517-676-5460
Practice Address - Street 1:632 N SHIAWASSEE ST
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-2232
Practice Address - Country:US
Practice Address - Phone:897-230-3309
Practice Address - Fax:989-723-0327
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4151001016101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor