Basic Information
| Provider Information | |||||||||
| NPI: | 1952073777 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | MEREDITH | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | APC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 PENINSULA CIR | ||||||||
| Address2: | |||||||||
| City: | NEWNAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302636094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788327769 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5480 MCGINNIS VILLAGE PL STE 104 | ||||||||
| Address2: | |||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300051746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782132194 | ||||||||
| FaxNumber: | 6789227767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2021 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | APC008215 | GA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.