Provider Demographics
NPI:1073549911
Name:ELLIS, PHILIP LEE (PHD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:LEE
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 S PARK ST
Mailing Address - Street 2:STE 325
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-3608
Mailing Address - Country:US
Mailing Address - Phone:231-715-8466
Mailing Address - Fax:
Practice Address - Street 1:300 68TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-6927
Practice Address - Country:US
Practice Address - Phone:616-455-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005230103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIS07629Medicare UPIN
MID16189033Medicare PIN