Provider Demographics
NPI:1003964131
Name:ELLIS, MARY LINDA (LPC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LINDA
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6120 MAPPERLEY LN
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-6176
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2070 BUFORD HWY
Practice Address - Street 2:STE 2-D
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-6079
Practice Address - Country:US
Practice Address - Phone:770-271-9442
Practice Address - Fax:770-271-8939
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003585101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional