Healthcare Provider Details

I. General information

NPI: 1487933859
Provider Name (Legal Business Name): TASHA J ELLIS PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2011
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7801 E BUSH LAKE RD STE 130
MINNEAPOLIS MN
55439-3152
US

IV. Provider business mailing address

2985 CENTRE POINTE DR # 230
ROSEVILLE MN
55113-1105
US

V. Phone/Fax

Practice location:
  • Phone: 763-244-4900
  • Fax:
Mailing address:
  • Phone: 310-390-6612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP6620
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP6620
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: