Provider Demographics
NPI:1053478503
Name:ELLIS, ELIZABETH MYRNA (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:MYRNA
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
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Mailing Address - Street 1:801 AMSTERDAM AVE NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-3403
Mailing Address - Country:US
Mailing Address - Phone:770-337-9446
Mailing Address - Fax:770-476-0377
Practice Address - Street 1:801 AMSTERDAM AVE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306-3403
Practice Address - Country:US
Practice Address - Phone:770-337-9446
Practice Address - Fax:770-476-0377
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA521103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00196171BMedicaid
Q12927Medicare UPIN
GA00196171BMedicaid