Provider Demographics
NPI:1891071700
Name:ELLIS, NATASHA ANTOINETTE (CPSS, CRC)
Entity Type:Individual
Prefix:MS
First Name:NATASHA
Middle Name:ANTOINETTE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:CPSS, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465 TAMARIND AVE 685
Mailing Address - Street 2:685
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028
Mailing Address - Country:US
Mailing Address - Phone:734-772-8640
Mailing Address - Fax:
Practice Address - Street 1:40075 EATON ST
Practice Address - Street 2:202
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-4500
Practice Address - Country:US
Practice Address - Phone:734-981-1442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist