Provider Demographics
NPI:1053826164
Name:ELLIS, JULIA ANN (LPC, LMT)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:ANN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LPC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2976 SUNSET RD
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-1832
Mailing Address - Country:US
Mailing Address - Phone:989-763-2196
Mailing Address - Fax:
Practice Address - Street 1:2976 SUNSET RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-1832
Practice Address - Country:US
Practice Address - Phone:989-763-2196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-12
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010426101Y00000X
MI7501000246225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor