Provider Demographics
NPI:1013395904
Name:BLACK, ELLIS LUCA (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLIS
Middle Name:LUCA
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LAURA
Other - Middle Name:ELIZABETH
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2711 E MADISON ST STE 204
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98112-4763
Mailing Address - Country:US
Mailing Address - Phone:206-984-3924
Mailing Address - Fax:206-339-1776
Practice Address - Street 1:2711 E MADISON ST STE 204
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-4763
Practice Address - Country:US
Practice Address - Phone:206-984-3924
Practice Address - Fax:206-339-1776
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD609370582084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry