Provider Demographics
NPI:1093591240
Name:ELLEM, BENJAMIN JOHN (PHD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JOHN
Last Name:ELLEM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:BENJAMIN
Other - Middle Name:JOHN
Other - Last Name:LAMAN-MAHARG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7341 WILDERNESS PARK DR APT 303
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-5974
Mailing Address - Country:US
Mailing Address - Phone:814-359-8850
Mailing Address - Fax:
Practice Address - Street 1:2215 FULLER RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-2303
Practice Address - Country:US
Practice Address - Phone:734-769-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist