Healthcare Provider Details

I. General information

NPI: 1295397404
Provider Name (Legal Business Name): MRS. TAMERA KATRINA ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TAMERA KATRINA RUTHERFORD

II. Dates (important events)

Enumeration Date: 07/08/2019
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 WEST ST
CEDAR SPRINGS MI
49319-9699
US

IV. Provider business mailing address

2990 WETMORE DR
ALLEGAN MI
49010-8538
US

V. Phone/Fax

Practice location:
  • Phone: 231-268-0360
  • Fax:
Mailing address:
  • Phone: 269-254-7063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: