=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194576967
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELLIS AND ASSOCIATES PSYCHOTHERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2024
-----------------------------------------------------
Last Update Date | 05/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4343 CONCOURSE DR STE 250
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48108-8672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-677-0200
-----------------------------------------------------
Fax | 734-677-3310
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4343 CONCOURSE DR STE 250
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48108-8672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-677-0200
-----------------------------------------------------
Fax | 734-677-3310
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL BILLER
-----------------------------------------------------
Name | LAURA J DURHAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 734-677-0200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------