Basic Information
| Provider Information | |||||||||
| NPI: | 1962733725 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 CLAY ST | ||||||||
| Address2: | |||||||||
| City: | MARTINSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241122810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2766327128 | ||||||||
| FaxNumber: | 2766320127 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 TECHNOLOGY DR | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241513008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5404835044 | ||||||||
| FaxNumber: | 5404830583 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2010 | ||||||||
| LastUpdateDate: | 01/19/2010 | ||||||||
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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 | 0701004749 | VA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 004945221 | 05 | VA | MEDICAID |