Healthcare Provider Details

I. General information

NPI: 1013395904
Provider Name (Legal Business Name): ELLIS LUCA BLACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA ELIZABETH BLACK MD

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 E MADISON ST STE 204
SEATTLE WA
98112-4763
US

IV. Provider business mailing address

2711 E MADISON ST STE 204
SEATTLE WA
98112-4763
US

V. Phone/Fax

Practice location:
  • Phone: 206-984-3924
  • Fax: 206-339-1776
Mailing address:
  • Phone: 206-984-3924
  • Fax: 206-339-1776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD60937058
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD60937058
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: