Provider Demographics
NPI:1417218868
Name:ELLIS, MEREDITH BROOKS (LMP)
Entity Type:Individual
Prefix:MS
First Name:MEREDITH
Middle Name:BROOKS
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 NE 89TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-3038
Mailing Address - Country:US
Mailing Address - Phone:206-524-5270
Mailing Address - Fax:
Practice Address - Street 1:5236 CALIFORNIA AVE SW
Practice Address - Street 2:SUITE D
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98136-1244
Practice Address - Country:US
Practice Address - Phone:206-331-3999
Practice Address - Fax:206-388-3226
Is Sole Proprietor?:No
Enumeration Date:2012-06-01
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60284701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist