Provider Demographics
NPI:1891060869
Name:ELLIOTT, PETER ROSS (LMSW, CAADC, CCS)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:ROSS
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:LMSW, CAADC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 BENJAMIN DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-3094
Mailing Address - Country:US
Mailing Address - Phone:734-483-1718
Mailing Address - Fax:313-346-3600
Practice Address - Street 1:15380 MONICA ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-1942
Practice Address - Country:US
Practice Address - Phone:313-345-3600
Practice Address - Fax:313-345-1586
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-09
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010467211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC-00023OtherMICHIGAN CERTIFICATION BOARD FOR ADDICTION PROFESSIONALS - CAADC
MI6801046721OtherDEPARTMENT OF COMMUNITY HEALTH BOARD OF SOCIAL WORK
MIC-J0012OtherMICHIGANB CERTIFICATION BOARD FOR ADDICTION PROFESSIONALS
MIS-00013OtherMICHIGAN CERTIFICATION BOARD FOR ADDICTION PROFESSIONALS - CCS