Provider Demographics
NPI:1558698654
Name:ELLIS, CHARMINE (BS CACM)
Entity Type:Individual
Prefix:MS
First Name:CHARMINE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:BS CACM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16647 WYOMING
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221
Mailing Address - Country:US
Mailing Address - Phone:313-342-3606
Mailing Address - Fax:313-861-0413
Practice Address - Street 1:16647 WYOMING
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221
Practice Address - Country:US
Practice Address - Phone:313-342-3606
Practice Address - Fax:313-861-0413
Is Sole Proprietor?:No
Enumeration Date:2009-11-10
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)