Provider Demographics
NPI:1932145729
Name:ELLENS, BRENT MICHAEL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:MICHAEL
Last Name:ELLENS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 68TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-6927
Mailing Address - Country:US
Mailing Address - Phone:616-455-5000
Mailing Address - Fax:
Practice Address - Street 1:720 E 8TH ST STE 2
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3079
Practice Address - Country:US
Practice Address - Phone:616-355-0549
Practice Address - Fax:616-355-0480
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011810103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP101976540OtherBC/BS
MIP53037Medicare UPIN
MIP101976540OtherBC/BS