MEDICARE: MR. PETER ROSS ELLIOTT LMSW, CAADC, CCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6801046721	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C-00023	OTHER	MI	MICHIGAN CERTIFICATION BOARD FOR ADDICTION PROFESSIONALS - CAADC
2	6801046721	OTHER	MI	DEPARTMENT OF COMMUNITY HEALTH BOARD OF SOCIAL WORK
3	C-J0012	OTHER	MI	MICHIGANB CERTIFICATION BOARD FOR ADDICTION PROFESSIONALS
4	S-00013	OTHER	MI	MICHIGAN CERTIFICATION BOARD FOR ADDICTION PROFESSIONALS - CCS

General Provider Information

NPI Number	:	1891060869
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PETER ROSS ELLIOTT LMSW, CAADC, CCS

Provider Business Mailing Address
First Line	:	300 BENJAMIN DR
Second Line	:
City	:	YPSILANTI
State	:	MI
Zip	:	48198-3094
Country	:	US
Telephone Number	:	734-483-1718
Fax Number	:	313-346-3600

Provider Business Practice Location Address
First Line	:	15380 MONICA ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48238-1942
Country	:	US
Telephone Number	:	313-345-3600
Fax Number	:	313-345-1586

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2012
Last Update Date	:	03/09/2012

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