Healthcare Provider Details

I. General information

NPI: 1467762393
Provider Name (Legal Business Name): MICHAEL FLINT ELLIS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2010
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 NELSON RD
ITHACA NY
14850-9452
US

IV. Provider business mailing address

91 NELSON RD
ITHACA NY
14850-9452
US

V. Phone/Fax

Practice location:
  • Phone: 607-239-7845
  • Fax:
Mailing address:
  • Phone: 607-239-7845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number085226
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: