1891071700 NPI number — MS. NATASHA ANTOINETTE ELLIS CPSS, CRC

Table of content: MS. NATASHA ANTOINETTE ELLIS CPSS, CRC (NPI 1891071700)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891071700 NPI number — MS. NATASHA ANTOINETTE ELLIS CPSS, CRC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIS
Provider First Name:
NATASHA
Provider Middle Name:
ANTOINETTE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CPSS, CRC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891071700
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1465 TAMARIND AVE 685
Provider Second Line Business Mailing Address:
685
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-772-8640
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40075 EATON ST
Provider Second Line Business Practice Location Address:
202
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48187-4500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-981-1442
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/25/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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