Provider Demographics
NPI:1790455152
Name:ELLIS, TERRELL TYRAY
Entity Type:Individual
Prefix:MR
First Name:TERRELL
Middle Name:TYRAY
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21408 INKSTER RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-5026
Mailing Address - Country:US
Mailing Address - Phone:949-472-2403
Mailing Address - Fax:947-941-2603
Practice Address - Street 1:21408 INKSTER RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-5026
Practice Address - Country:US
Practice Address - Phone:947-224-0379
Practice Address - Fax:947-941-2603
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker