Healthcare Provider Details

I. General information

NPI: 1447636634
Provider Name (Legal Business Name): CATHY ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2015
Last Update Date: 08/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35425 W MICHIGAN AVE
WAYNE MI
48184-9800
US

IV. Provider business mailing address

13880 CAMBRIDGE ST APT 123
SOUTHGATE MI
48195-1681
US

V. Phone/Fax

Practice location:
  • Phone: 734-467-7600
  • Fax:
Mailing address:
  • Phone: 734-218-4292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801098342
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: