Provider Demographics
NPI:1659766186
Name:ELLIS, MICHELLE MATSON (MACP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MATSON
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MACP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:KAY
Other - Last Name:MATSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MACP
Mailing Address - Street 1:4518 SCHOONER DR
Mailing Address - Street 2:
Mailing Address - City:ANACORTES
Mailing Address - State:WA
Mailing Address - Zip Code:98221-4060
Mailing Address - Country:US
Mailing Address - Phone:206-890-2417
Mailing Address - Fax:
Practice Address - Street 1:1809 COMMERCIAL AVE STE 207
Practice Address - Street 2:
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221-2326
Practice Address - Country:US
Practice Address - Phone:425-892-4997
Practice Address - Fax:425-952-6918
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-01
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60742082101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health