Provider Demographics
NPI:1467945113
Name:ELLIOTT, ERICA (LCDC III)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 N DETROIT ST
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-2909
Mailing Address - Country:US
Mailing Address - Phone:513-892-4673
Mailing Address - Fax:513-737-1107
Practice Address - Street 1:36 N DETROIT ST
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-2909
Practice Address - Country:US
Practice Address - Phone:513-892-4673
Practice Address - Fax:513-737-1107
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.162031101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0291136Medicaid