Healthcare Provider Details

I. General information

NPI: 1215159587
Provider Name (Legal Business Name): ELLYN BARRITA OBRA RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14560 LAKESIDE CIRCLE
STERLING HEIGHTS MI
48313
US

IV. Provider business mailing address

37764 IRENE DR
STERLING HEIGJHTS MI
48312
US

V. Phone/Fax

Practice location:
  • Phone: 586-247-3220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501011973
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: