Basic Information
| Provider Information | |||||||||
| NPI: | 1073160776 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLMANN | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | MA, LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6458 CITY WEST PKWY | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553443245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9527676960 | ||||||||
| FaxNumber: | 6127285301 | ||||||||
| Practice Location | |||||||||
| Address1: | 6458 CITY WEST PKWY | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553443245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9527676960 | ||||||||
| FaxNumber: | 6127285301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2019 | ||||||||
| LastUpdateDate: | 08/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | CC02183 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.