Provider Demographics
NPI:1932564697
Name:ELLIOTT, JOB (LISAC, LAC)
Entity Type:Individual
Prefix:
First Name:JOB
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:LISAC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 W SAINT CHARLES AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-4980
Mailing Address - Country:US
Mailing Address - Phone:480-233-5511
Mailing Address - Fax:
Practice Address - Street 1:4105 W SAINT CHARLES AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041
Practice Address - Country:US
Practice Address - Phone:480-233-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-23
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-15039101YA0400X
AZLAC-15368101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor