Provider Demographics
NPI:1619636784
Name:ELLIOTT, TERRI
Entity type:Individual
Prefix:
First Name:TERRI
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3291 W 91ST ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102-4831
Mailing Address - Country:US
Mailing Address - Phone:216-272-3178
Mailing Address - Fax:
Practice Address - Street 1:3291 W 91ST ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-4831
Practice Address - Country:US
Practice Address - Phone:216-272-3178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-15
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH185962101YA0400X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty