Healthcare Provider Details

I. General information

NPI: 1699700666
Provider Name (Legal Business Name): MICHAEL V ELLIS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 04/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1A PINE WEST PLZ
ALBANY NY
12205-5557
US

IV. Provider business mailing address

4 BERKSHIRE DR W
CLIFTON PARK NY
12065-1741
US

V. Phone/Fax

Practice location:
  • Phone: 518-416-9500
  • Fax: 518-862-1668
Mailing address:
  • Phone: 518-862-1533
  • Fax: 518-716-4880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number008630
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: