Provider Demographics
NPI:1922469170
Name:ELLIOTT, JUSTIN MICHAEL (OTRL)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4621 ASHLAND DR
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48638
Mailing Address - Country:US
Mailing Address - Phone:989-482-6869
Mailing Address - Fax:
Practice Address - Street 1:1149 W MONROE RD
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MI
Practice Address - Zip Code:48880
Practice Address - Country:US
Practice Address - Phone:989-681-3852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009383225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist