Provider Demographics
NPI:1841826955
Name:ELISHA ETIENNE LLC
Entity type:Organization
Organization Name:ELISHA ETIENNE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:FRANCINE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:734-985-3085
Mailing Address - Street 1:4720 ROMEO LN
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-8699
Mailing Address - Country:US
Mailing Address - Phone:734-985-3085
Mailing Address - Fax:
Practice Address - Street 1:4720 ROMEO LN
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-8699
Practice Address - Country:US
Practice Address - Phone:734-985-3085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-20
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No251B00000XAgenciesCase Management
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health