Provider Demographics
NPI:1396743704
Name:TABAK, ELLEN ROSE (ACSW, MA)
Entity type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:ROSE
Last Name:TABAK
Suffix:
Gender:F
Credentials:ACSW, MA
Other - Prefix:MS
Other - First Name:ELLEN
Other - Middle Name:ROSE
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ACSW, MA
Mailing Address - Street 1:1960 GOLF RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-1725
Mailing Address - Country:US
Mailing Address - Phone:248-538-9666
Mailing Address - Fax:248-538-9666
Practice Address - Street 1:101 W LONG LAKE RD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-2749
Practice Address - Country:US
Practice Address - Phone:248-480-4965
Practice Address - Fax:248-480-4966
Is Sole Proprietor?:No
Enumeration Date:2005-07-09
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010184781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI382778765OtherCIGNA / VENDOR # 1139981
MI750910718OtherBLUE CROSS BLUE SHIELD
247423000OtherMAGELLAN BEHAVIORAL OF MI
51940-01OtherMT CARMEL BEHAVIORAL HLTH
9359445OtherPRIVATE HEALTHCARE SYSTEM