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General NPI Number Information
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NPI Number | 1790455152
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Entity Type | Individual
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Provider Name | MR. TERRELL TYRAY ELLIS
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Gender | Male
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Dates
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Enumeration Date | 09/16/2021
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Last Update Date | 09/16/2021
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Provider Practice Location Address
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Address Line | 21408 INKSTER RD
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City | SOUTHFIELD
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State | MI
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Zip | 48033-5026
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Country | US
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Telephone | 947-224-0379
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Fax | 947-941-2603
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Provider Business Mailing Address
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Address Line | 21408 INKSTER RD
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City | SOUTHFIELD
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State | MI
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Zip | 48033-5026
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Country | US
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Telephone | 949-472-2403
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Fax | 947-941-2603
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 374U00000X
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Taxonomy Name | Home Health Aide
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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Taxonomy #3
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Taxonomy Code | 376J00000X
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Taxonomy Name | Homemaker
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