=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386797892
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER LEIGH ELLIS LBSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2007
-----------------------------------------------------
Last Update Date | 01/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3665 BAY RD
-----------------------------------------------------
City | SAGINAW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48603-2445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-799-6542
-----------------------------------------------------
Fax | 989-799-6681
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 HANCOCK SAGINAW COUNTY COMMUNITY MENTAL HEALTH AUTHORITY
-----------------------------------------------------
City | SAGINAW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-797-3400
-----------------------------------------------------
Fax | 989-797-3522
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | 6802084108
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------