Provider Demographics
NPI:1174624951
Name:ELLIS, MICHAEL SEWARD (LCSW)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:SEWARD
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 WINDEL DR STE 213
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-4471
Mailing Address - Country:US
Mailing Address - Phone:919-781-2750
Mailing Address - Fax:919-477-6122
Practice Address - Street 1:107 WINDEL DR STE 213
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-4471
Practice Address - Country:US
Practice Address - Phone:919-781-2750
Practice Address - Fax:919-477-6122
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0011351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical