Provider Demographics
NPI:1013090679
Name:ELLIS-CHOPIN, DEANNA RENAE (PSYCHOLOGIST)
Entity type:Individual
Prefix:DR
First Name:DEANNA
Middle Name:RENAE
Last Name:ELLIS-CHOPIN
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:DR
Other - First Name:DEANNA
Other - Middle Name:RENAE
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 8776
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49023-8776
Mailing Address - Country:US
Mailing Address - Phone:269-369-1753
Mailing Address - Fax:
Practice Address - Street 1:1800 PIPESTONE RD # 8776
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-2311
Practice Address - Country:US
Practice Address - Phone:269-369-1753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 103TA0400X
MI6301010775103TM1800X
MI6361000635103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities