Healthcare Provider Details

I. General information

NPI: 1902716418
Provider Name (Legal Business Name): STACY ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E GREEN ST
MARSHALL MI
49068-1533
US

IV. Provider business mailing address

420 WHISPERING PNES N
MARSHALL MI
49068-9645
US

V. Phone/Fax

Practice location:
  • Phone: 269-358-8967
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: