Provider Demographics
NPI:1881785871
Name:ELLIS, MADELEINE C (PHD)
Entity type:Individual
Prefix:DR
First Name:MADELEINE
Middle Name:C
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MAGGIE
Other - Middle Name:C
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:31620 23RD AVE S
Mailing Address - Street 2:318
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-5064
Mailing Address - Country:US
Mailing Address - Phone:253-941-9779
Mailing Address - Fax:
Practice Address - Street 1:31620 23RD AVE S
Practice Address - Street 2:318
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5064
Practice Address - Country:US
Practice Address - Phone:253-941-9779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00004075101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health