Provider Demographics
NPI:1609311315
Name:ELLIS, MICHAEL MARIO
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:MARIO
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 MONACO CT
Mailing Address - Street 2:#28
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6742
Mailing Address - Country:US
Mailing Address - Phone:209-644-6328
Mailing Address - Fax:209-644-6308
Practice Address - Street 1:1222 MONACO CT
Practice Address - Street 2:#28
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6742
Practice Address - Country:US
Practice Address - Phone:209-644-6328
Practice Address - Fax:209-644-6308
Is Sole Proprietor?:No
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)