Provider Demographics
NPI:1386416352
Name:ELLIS, MICHAEL SHAWN (LPC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SHAWN
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:S
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1208 E CHURCHVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-3442
Mailing Address - Country:US
Mailing Address - Phone:410-839-4600
Mailing Address - Fax:
Practice Address - Street 1:45 RIVERVIEW RD
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513-4637
Practice Address - Country:US
Practice Address - Phone:203-915-9540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-24
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6868101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional