Healthcare Provider Details

I. General information

NPI: 1013090679
Provider Name (Legal Business Name): DEANNA RENAE ELLIS-CHOPIN PSYCHOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DR. DEANNA RENAE ELLIS

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 PIPESTONE RD # 8776
BENTON HARBOR MI
49022-2311
US

IV. Provider business mailing address

PO BOX 8776
BENTON HARBOR MI
49023-8776
US

V. Phone/Fax

Practice location:
  • Phone: 269-369-1753
  • Fax:
Mailing address:
  • Phone: 269-369-1753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number6301010775
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6361000635
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: