Provider Demographics
NPI:1801348628
Name:ELLIS, MICAH (LAC, CMT, MSTCM)
Entity type:Individual
Prefix:MRS
First Name:MICAH
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LAC, CMT, MSTCM
Other - Prefix:MISS
Other - First Name:MICAH
Other - Middle Name:
Other - Last Name:HELMBECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3216 FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94123-3403
Mailing Address - Country:US
Mailing Address - Phone:415-590-2899
Mailing Address - Fax:
Practice Address - Street 1:3216 FILLMORE ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94123-3403
Practice Address - Country:US
Practice Address - Phone:415-590-2899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-27
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 17410171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist