Provider Demographics
NPI:1750482253
Name:ELLIS, MICHELLE ANDREE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:ANDREE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4040 E CORONADO
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-1514
Mailing Address - Country:US
Mailing Address - Phone:520-425-3456
Mailing Address - Fax:520-319-9712
Practice Address - Street 1:639 E SPEEDWAY
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705
Practice Address - Country:US
Practice Address - Phone:520-425-3456
Practice Address - Fax:520-319-9712
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1319103T00000X, 103TC0700X, 103TC2200X, 103TS0200X
AZAZ1319103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ428799Medicaid
AZZ138347Medicare PIN
AZG97260Medicare UPIN