Provider Demographics
NPI:1699700666
Name:ELLIS, MICHAEL V (PHD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:V
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 BERKSHIRE DR W
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-1741
Mailing Address - Country:US
Mailing Address - Phone:518-862-1533
Mailing Address - Fax:518-716-4880
Practice Address - Street 1:1A PINE WEST PLZ
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-5557
Practice Address - Country:US
Practice Address - Phone:518-416-9500
Practice Address - Fax:518-862-1668
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008630103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5527BMedicare ID - Type Unspecified