=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689186363
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOYCELYNN YVONNE GLOVER ELLISON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2017
-----------------------------------------------------
Last Update Date | 11/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 718 OAK ST
-----------------------------------------------------
City | FLINT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48503-2614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-233-8815
-----------------------------------------------------
Fax | 810-833-8812
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 106 CHEROKEE RD
-----------------------------------------------------
City | PONTIAC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48341-1504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-396-8061
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 6301017251
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------