=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093520348
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RENAY ELLISON LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2025
-----------------------------------------------------
Last Update Date | 02/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7100 STADIUM DR
-----------------------------------------------------
City | KALAMAZOO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49009-9423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-345-0273
-----------------------------------------------------
Fax | 269-345-8522
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7338 WHITE RABBIT RD
-----------------------------------------------------
City | BATTLE CREEK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49017-9429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-274-4896
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801118787
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------