Provider Demographics
NPI:1194051557
Name:ELLIS, NIAAH (BAHCS)
Entity type:Individual
Prefix:MS
First Name:NIAAH
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:BAHCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20226 SANTA ROSA DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-1291
Mailing Address - Country:US
Mailing Address - Phone:313-221-3352
Mailing Address - Fax:
Practice Address - Street 1:4812 E. MCNICHOLS
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48212
Practice Address - Country:US
Practice Address - Phone:313-368-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)