Basic Information
| Provider Information | |||||||||
| NPI: | 1801383989 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TOBIN | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MURPHY | ||||||||
| OtherFirstName: | ELLEN | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3300 36TH ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495122810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169422110 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1785 WEST STADIUM BLVD HERON RIDGE ASSOCIATES | ||||||||
| Address2: | SUITE #205 | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349131093 | ||||||||
| FaxNumber: | 7343692683 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2018 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6401016604 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.