Provider Demographics
NPI:1467762393
Name:ELLIS, MICHAEL FLINT (LMSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:FLINT
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 RACHEL CARSON WAY
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-8401
Mailing Address - Country:US
Mailing Address - Phone:607-239-7247
Mailing Address - Fax:
Practice Address - Street 1:230 RACHEL CARSON WAY
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-8401
Practice Address - Country:US
Practice Address - Phone:607-239-7247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-13
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY066334101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health