Provider Demographics
NPI:1679941751
Name:ELLIS PROFESSIONAL COUNSELING SERVICES, LLC
Entity type:Organization
Organization Name:ELLIS PROFESSIONAL COUNSELING SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:A
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:270-401-5450
Mailing Address - Street 1:3651 SHEPHERDSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-9511
Mailing Address - Country:US
Mailing Address - Phone:270-401-5450
Mailing Address - Fax:270-360-0767
Practice Address - Street 1:3651 SHEPHERDSVILLE RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-9511
Practice Address - Country:US
Practice Address - Phone:270-401-5450
Practice Address - Fax:270-360-0767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYLPCPCC00216428101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100355870Medicaid