MEDICARE: MRS. ELLEN ROSE TABAK ACSW, M.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6801018478	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	382778765	OTHER	MI	CIGNA / VENDOR # 1139981
2	750910718	OTHER	MI	BLUE CROSS BLUE SHIELD
3	247423000	OTHER		MAGELLAN BEHAVIORAL OF MI
4	51940-01	OTHER		MT CARMEL BEHAVIORAL HLTH
5	9359445	OTHER		PRIVATE HEALTHCARE SYSTEM

General Provider Information

NPI Number	:	1396743704
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELLEN ROSE TABAK ACSW, M.A.

Provider Business Mailing Address
First Line	:	1960 GOLF RIDGE DR
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48302-1725
Country	:	US
Telephone Number	:	248-538-9666
Fax Number	:	248-538-9666

Provider Business Practice Location Address
First Line	:	101 W LONG LAKE RD
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48304-2749
Country	:	US
Telephone Number	:	248-480-4965
Fax Number	:	248-480-4966

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2005
Last Update Date	:	10/07/2019

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