Basic Information
| Provider Information | |||||||||
| NPI: | 1578290227 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | LU ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1820 S 25TH AVE | ||||||||
| Address2: | |||||||||
| City: | BROADVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601553960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086810073 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1325 N HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605061449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309067015 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2022 | ||||||||
| LastUpdateDate: | 08/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 101YM0800X | IL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.