Provider Demographics
NPI:1043242340
Name:ELLIS, CATHERINE E (MA)
Entity Type:Individual
Prefix:MS
First Name:CATHERINE
Middle Name:E
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 HUDSON AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-1889
Mailing Address - Country:US
Mailing Address - Phone:269-341-9725
Mailing Address - Fax:269-341-9735
Practice Address - Street 1:2001 HUDSON AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-1889
Practice Address - Country:US
Practice Address - Phone:269-341-9725
Practice Address - Fax:269-341-9735
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007514103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical