Provider Demographics
NPI:1558584789
Name:ELLIS, EMMY RUTH (MSW)
Entity Type:Individual
Prefix:MS
First Name:EMMY
Middle Name:RUTH
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 BALL AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-5904
Mailing Address - Country:US
Mailing Address - Phone:616-456-6571
Mailing Address - Fax:616-458-0095
Practice Address - Street 1:1101 BALL AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5904
Practice Address - Country:US
Practice Address - Phone:616-456-6571
Practice Address - Fax:616-458-0095
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801071820104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker