Provider Demographics
NPI:1184143463
Name:BURRELL, REELLA LEE
Entity type:Individual
Prefix:
First Name:REELLA
Middle Name:LEE
Last Name:BURRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6345 ANGLING RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-1703
Mailing Address - Country:US
Mailing Address - Phone:269-348-4375
Mailing Address - Fax:269-743-7134
Practice Address - Street 1:6345 ANGLING RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-1703
Practice Address - Country:US
Practice Address - Phone:269-312-8885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-18
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF390382592320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities