Provider Demographics
NPI:1043684640
Name:ELLIOTT, JOHNATHAN PATRICK (MS, NCC, CCTP)
Entity type:Individual
Prefix:MR
First Name:JOHNATHAN
Middle Name:PATRICK
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:MS, NCC, CCTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 HARD RD
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-8825
Mailing Address - Country:US
Mailing Address - Phone:585-347-1045
Mailing Address - Fax:585-347-1277
Practice Address - Street 1:860 HARD RD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-8825
Practice Address - Country:US
Practice Address - Phone:585-347-1045
Practice Address - Fax:585-347-1277
Is Sole Proprietor?:No
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP00184101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health