Provider Demographics
NPI:1689186363
Name:GLOVER ELLISON, JOYCELYNN YVONNE
Entity Type:Individual
Prefix:
First Name:JOYCELYNN
Middle Name:YVONNE
Last Name:GLOVER ELLISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOYCELYNN
Other - Middle Name:YVONNE
Other - Last Name:GLOVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, TLLP
Mailing Address - Street 1:106 CHEROKEE RD
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-1504
Mailing Address - Country:US
Mailing Address - Phone:248-396-8061
Mailing Address - Fax:
Practice Address - Street 1:718 OAK ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2614
Practice Address - Country:US
Practice Address - Phone:810-233-8815
Practice Address - Fax:810-833-8812
Is Sole Proprietor?:No
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017251103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical