Provider Demographics
NPI:1275076630
Name:ELLMER, LORI A (LMSW)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:A
Last Name:ELLMER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37585 PAW PAW RD
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-9755
Mailing Address - Country:US
Mailing Address - Phone:269-214-6287
Mailing Address - Fax:
Practice Address - Street 1:181 W MICHIGAN AVE STE 3
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1432
Practice Address - Country:US
Practice Address - Phone:269-657-6025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-02
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011111631041C0700X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical