Provider Demographics
NPI:1417973850
Name:ELLIS, KENNETH J (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
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 1:1106 COLUMBIA AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-4335
Mailing Address - Country:US
Mailing Address - Phone:360-653-0374
Mailing Address - Fax:360-658-0219
Practice Address - Street 1:1106 COLUMBIA AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-4335
Practice Address - Country:US
Practice Address - Phone:360-653-0374
Practice Address - Fax:360-658-0219
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00003392103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8856382Medicare ID - Type Unspecified
WAR76980Medicare UPIN