MEDICARE: MICHAEL FREDERICK ELLIS LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0904011034	VA

General Provider Information

NPI Number	:	1184288961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL FREDERICK ELLIS LCSW

Provider Business Mailing Address
First Line	:	118 DUWAMISH TRL
Second Line	:
City	:	WINCHESTER
State	:	VA
Zip	:	22602-1314
Country	:	US
Telephone Number	:	540-431-7376
Fax Number	:

Provider Business Practice Location Address
First Line	:	2913 PLEASANT VALLEY AVENUE
Second Line	:	SUITE 125
City	:	WINCHESTER
State	:	VA
Zip	:	22601
Country	:	US
Telephone Number	:	540-431-7376
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2019
Last Update Date	:	04/26/2019

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