Healthcare Provider Details

I. General information

NPI: 1750482253
Provider Name (Legal Business Name): MICHELLE ANDREE ELLIS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 10/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

639 E SPEEDWAY
TUCSON AZ
85705
US

IV. Provider business mailing address

4040 E CORONADO
TUCSON AZ
85718-1514
US

V. Phone/Fax

Practice location:
  • Phone: 520-425-3456
  • Fax: 520-319-9712
Mailing address:
  • Phone: 520-425-3456
  • Fax: 520-319-9712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1319
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1319
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number1319
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1319
License Number StateAZ
# 5
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberAZ1319
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: