Provider Demographics
NPI:1184110520
Name:ELLIS, BRANDI MICHELLE (PHD)
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:MICHELLE
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 1:1720 2ND AVENUE SOUTH, CH19 SUITE 307
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35294-2041
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:930 20TH ST S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-2610
Practice Address - Country:US
Practice Address - Phone:205-934-5471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2281103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical