Provider Demographics
NPI:1184288961
Name:ELLIS, MICHAEL FREDERICK (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:FREDERICK
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 DUWAMISH TRL
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22602-1314
Mailing Address - Country:US
Mailing Address - Phone:540-431-7376
Mailing Address - Fax:
Practice Address - Street 1:2913 PLEASANT VALLEY AVENUE
Practice Address - Street 2:SUITE 125
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601
Practice Address - Country:US
Practice Address - Phone:540-431-7376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040110341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical