Provider Demographics
NPI:1295039998
Name:ELLISOR, MICHELLE A (LMFT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:ELLISOR
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4806 PARK LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78732-1733
Mailing Address - Country:US
Mailing Address - Phone:512-294-5595
Mailing Address - Fax:
Practice Address - Street 1:4601 SPICEWOOD SPRINGS RD
Practice Address - Street 2:BUILDING 4, SUITE 200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8598
Practice Address - Country:US
Practice Address - Phone:512-467-1376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-10
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX201652106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist