Provider Demographics
NPI:1710921275
Name:ELLISON, SANDRA PEPPERCORN (MA, LLP)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:PEPPERCORN
Last Name:ELLISON
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:MS
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:PEPPERCORN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, LLP
Mailing Address - Street 1:28511 ORCHARD LAKE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-2933
Mailing Address - Country:US
Mailing Address - Phone:248-489-1550
Mailing Address - Fax:248-489-9767
Practice Address - Street 1:28511 ORCHARD LAKE RD
Practice Address - Street 2:SUITE A
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-2933
Practice Address - Country:US
Practice Address - Phone:248-489-1550
Practice Address - Fax:248-489-9767
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801065312103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist