Healthcare Provider Details

I. General information

NPI: 1194653303
Provider Name (Legal Business Name): RAVEN ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19177 NEGAUNEE
REDFORD MI
48240-1637
US

IV. Provider business mailing address

40315 MICHIGAN AVE
CANTON MI
48188-2908
US

V. Phone/Fax

Practice location:
  • Phone: 734-312-8968
  • Fax:
Mailing address:
  • Phone: 734-312-8968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number900079658
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: