Provider Demographics
NPI:1104646645
Name:ELLIS, TAMMY RENEE
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:RENEE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:RENEE
Other - Last Name:SCHAFER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3642 PALMS RD
Mailing Address - Street 2:
Mailing Address - City:CASCO
Mailing Address - State:MI
Mailing Address - Zip Code:48064-2103
Mailing Address - Country:US
Mailing Address - Phone:586-477-8618
Mailing Address - Fax:
Practice Address - Street 1:33875 KIELY DR
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48047-3604
Practice Address - Country:US
Practice Address - Phone:586-725-6030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502002187225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant