MEDICARE: MIKAL ELLIS

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101Y00000X	Counselor
2	101YA0400X	Addiction (Substance Use Disorder) Counselor
3	101YM0800X	Mental Health Counselor
4	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1912605213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIKAL ELLIS

Provider Business Mailing Address
First Line	:	2551 N 16TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19132-3908
Country	:	US
Telephone Number	:	215-800-8031
Fax Number	:

Provider Business Practice Location Address
First Line	:	2551 N 16TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19132-3908
Country	:	US
Telephone Number	:	215-800-8031
Fax Number	:

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

Provider Enumeration Date	:	02/16/2023
Last Update Date	:	02/16/2023

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Directions to “ MIKAL ELLIS ” Practice Location

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