Provider Demographics
NPI:1477595031
Name:ELLENS, EMILY ANNE (MA, LLP)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:ANNE
Last Name:ELLENS
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6328 VILLAGE LN
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-8250
Mailing Address - Country:US
Mailing Address - Phone:616-990-3402
Mailing Address - Fax:
Practice Address - Street 1:300 S STATE ST STE 13
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-1678
Practice Address - Country:US
Practice Address - Phone:616-772-1733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012310103T00000X
MI6361000735103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist