Basic Information
| Provider Information | |||||||||
| NPI: | 1629447966 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLICOTT CLINKSCALE | ||||||||
| FirstName: | DAWN | ||||||||
| MiddleName: | ELAINE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4740 N STATE ROAD 7 | ||||||||
| Address2: | |||||||||
| City: | LAUDERDALE LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333195839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544864005 | ||||||||
| FaxNumber: | 9544973857 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 N STATE ROAD 7 | ||||||||
| Address2: | |||||||||
| City: | LAUDERDALE LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333195800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9546348096 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2015 | ||||||||
| LastUpdateDate: | 04/08/2019 | ||||||||
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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 | 101YM0800X | MT3549 | FL | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | MFTMFT00221521 | KY | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 1041C0700X | MT3549 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.