Provider Demographics
NPI:1649598616
Name:ELLISON, MICHAEL JAMES (BS EDUCATION)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:ELLISON
Suffix:
Gender:M
Credentials:BS EDUCATION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 FRISCO AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:OK
Mailing Address - Zip Code:73601-3320
Mailing Address - Country:US
Mailing Address - Phone:580-323-9100
Mailing Address - Fax:580-323-9101
Practice Address - Street 1:703 FRISCO AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-3320
Practice Address - Country:US
Practice Address - Phone:580-323-9100
Practice Address - Fax:580-323-9101
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-14
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker