Provider Demographics
NPI:1043786916
Name:ELLISON, GABRIELLE RENEE (LCPC)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:RENEE
Last Name:ELLISON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 E 42ND ST APT 3E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-4857
Mailing Address - Country:US
Mailing Address - Phone:773-540-1179
Mailing Address - Fax:
Practice Address - Street 1:209 E 42ND ST APT 3E
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-4857
Practice Address - Country:US
Practice Address - Phone:773-540-1179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IL180.013708101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
$$$$$$$$$OtherCOMMUNITY MENTAL/BEHAVIOR HEALTH