Provider Demographics
NPI:1225526833
Name:ISSA, ELLISA D
Entity Type:Individual
Prefix:
First Name:ELLISA
Middle Name:D
Last Name:ISSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 E ELM AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-2649
Mailing Address - Country:US
Mailing Address - Phone:734-307-8794
Mailing Address - Fax:
Practice Address - Street 1:36 E ELM AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-2649
Practice Address - Country:US
Practice Address - Phone:734-307-8794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician