Provider Demographics
NPI:1629691217
Name:ELLIS, MIKE H
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:H
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-4504
Mailing Address - Country:US
Mailing Address - Phone:908-546-8947
Mailing Address - Fax:
Practice Address - Street 1:1950 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-4504
Practice Address - Country:US
Practice Address - Phone:908-546-8947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00225500101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty