Provider Demographics
NPI:1295397404
Name:ELLIS, TAMERA KATRINA
Entity Type:Individual
Prefix:MRS
First Name:TAMERA
Middle Name:KATRINA
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMERA
Other - Middle Name:KATRINA
Other - Last Name:RUTHERFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2990 WETMORE DR
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-8538
Mailing Address - Country:US
Mailing Address - Phone:269-254-7063
Mailing Address - Fax:
Practice Address - Street 1:4234 CASCADE RD SE STE 3
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8384
Practice Address - Country:US
Practice Address - Phone:616-202-4840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician