Healthcare Provider Details

I. General information

NPI: 1649471889
Provider Name (Legal Business Name): ELLEN VIOLET MICHAEL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 KNECHTEL WAY NE STE. 102
BAINBRIDGE ISLAND WA
98110-2860
US

IV. Provider business mailing address

345 KNECHTEL WAY NE STE. 102
BAINBRIDGE ISLAND WA
98110-2860
US

V. Phone/Fax

Practice location:
  • Phone: 206-780-6779
  • Fax: 206-780-7923
Mailing address:
  • Phone: 206-780-6779
  • Fax: 206-780-7923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License NumberMD00037545
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: