Basic Information
| Provider Information | |||||||||
| NPI: | 1245605286 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | IVETTE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 GOODYEAR AVE | ||||||||
| Address2: | |||||||||
| City: | CARTERSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301202587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703348544 | ||||||||
| FaxNumber: | 7703348656 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 GOODYEAR AVE | ||||||||
| Address2: | |||||||||
| City: | CARTERSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301202587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703348544 | ||||||||
| FaxNumber: | 7703348656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2015 | ||||||||
| LastUpdateDate: | 12/02/2015 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.