Healthcare Provider Details

I. General information

NPI: 1457400806
Provider Name (Legal Business Name): ELLA E M BROWN CHARITABLE CIRCLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 11/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15209 W MICHIGAN AVE
MARSHALL MI
49068-9570
US

IV. Provider business mailing address

200 N MADISON ST
MARSHALL MI
49068-1143
US

V. Phone/Fax

Practice location:
  • Phone: 269-781-9119
  • Fax:
Mailing address:
  • Phone: 269-781-4271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MICHELE DE SMET
Title or Position: FINANCIAL PLANNING & REIMBURSEMENT
Credential:
Phone: 269-781-4271