Provider Demographics
NPI:1962619031
Name:ELLIS, JOHN PAUL (PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:PAUL
Last Name:ELLIS
Suffix:
Gender:
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 GRAND AVENUE
Mailing Address - Street 2:#2
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-2614
Mailing Address - Country:US
Mailing Address - Phone:651-228-0218
Mailing Address - Fax:
Practice Address - Street 1:1108 GRAND AVENUE
Practice Address - Street 2:#2
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-2614
Practice Address - Country:US
Practice Address - Phone:651-228-0218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2025-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1642103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist