Healthcare Provider Details

I. General information

NPI: 1386797892
Provider Name (Legal Business Name): HEATHER LEIGH ELLIS LBSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 01/27/2020
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3665 BAY RD
SAGINAW MI
48603-2445
US

IV. Provider business mailing address

500 HANCOCK SAGINAW COUNTY COMMUNITY MENTAL HEALTH AUTHORITY
SAGINAW MI
48602
US

V. Phone/Fax

Practice location:
  • Phone: 989-799-6542
  • Fax: 989-799-6681
Mailing address:
  • Phone: 989-797-3400
  • Fax: 989-797-3522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number6802084108
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: