Healthcare Provider Details

I. General information

NPI: 1295890259
Provider Name (Legal Business Name): GAYLE M. ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 RAY O VAC DR SUITE 220
MADISON WI
53711-2479
US

IV. Provider business mailing address

700 RAY O VAC DR SUITE 220
MADISON WI
53711-2479
US

V. Phone/Fax

Practice location:
  • Phone: 608-276-9191
  • Fax: 608-276-9144
Mailing address:
  • Phone: 608-276-9191
  • Fax: 608-276-9144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2432-057
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1526-033
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: