Basic Information
| Provider Information | |||||||||
| NPI: | 1215159587 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OBRA | ||||||||
| FirstName: | ELLYN | ||||||||
| MiddleName: | BARRITA | ||||||||
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| Credential: | RPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 37764 IRENE DR | ||||||||
| Address2: | |||||||||
| City: | STERLING HEIGJHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48312 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 14560 LAKESIDE CIRCLE | ||||||||
| Address2: | |||||||||
| City: | STERLING HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862473220 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501011973 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.