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General NPI Number Information
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NPI Number | 1750482253
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Entity Type | Individual
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Provider Name | MICHELLE ANDREE ELLIS PHD
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Gender | Female
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Dates
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Enumeration Date | 09/26/2006
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Last Update Date | 10/27/2014
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Provider Practice Location Address
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Address Line | 639 E SPEEDWAY
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City | TUCSON
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State | AZ
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Zip | 85705
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Country | US
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Telephone | 520-425-3456
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Fax | 520-319-9712
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Provider Business Mailing Address
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Address Line | 4040 E CORONADO
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City | TUCSON
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State | AZ
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Zip | 85718-1514
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Country | US
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Telephone | 520-425-3456
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Fax | 520-319-9712
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 1319
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1319
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License Number State | AZ
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Taxonomy #3
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | 1319
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License Number State | AZ
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Taxonomy #4
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | 1319
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License Number State | AZ
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Taxonomy #5
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | AZ1319
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License Number State | AZ
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