Provider Demographics
NPI:1447688510
Name:ELLIS, DUANE FRANK (MA)
Entity type:Individual
Prefix:MR
First Name:DUANE
Middle Name:FRANK
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 W MICHIGAN ST
Mailing Address - Street 2:SUITE 12
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-2492
Mailing Address - Country:US
Mailing Address - Phone:989-317-4664
Mailing Address - Fax:
Practice Address - Street 1:304 W MICHIGAN ST
Practice Address - Street 2:SUITE 12
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2492
Practice Address - Country:US
Practice Address - Phone:989-317-4664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-28
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013459101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional