Provider Demographics
NPI:1770730434
Name:ELLIS, KURT THOMAS (LLP)
Entity type:Individual
Prefix:MR
First Name:KURT
Middle Name:THOMAS
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4829 E BELTLINE AVE NE
Mailing Address - Street 2:STE 103
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9349
Mailing Address - Country:US
Mailing Address - Phone:616-217-8612
Mailing Address - Fax:
Practice Address - Street 1:4920 PLAINFIELD AVE NE
Practice Address - Street 2:SUITE C
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-1010
Practice Address - Country:US
Practice Address - Phone:616-217-8612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008881103TC1900X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily