Provider Demographics
NPI:1730813700
Name:ELLIS, MATTHEW (BA, LADC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:BA, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2217 NICOLLET AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3382
Mailing Address - Country:US
Mailing Address - Phone:612-767-0309
Mailing Address - Fax:
Practice Address - Street 1:2217 NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3382
Practice Address - Country:US
Practice Address - Phone:612-294-9263
Practice Address - Fax:612-870-3796
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305037101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN305037Medicaid