Provider Demographics
NPI:1053097899
Name:ELLIS, GABRIEL MAXWELL (LPC)
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:MAXWELL
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3678 FOX TAIL DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-6246
Mailing Address - Country:US
Mailing Address - Phone:956-229-9201
Mailing Address - Fax:
Practice Address - Street 1:2219 LOWES DR W
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-6888
Practice Address - Country:US
Practice Address - Phone:931-614-7397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty