Provider Demographics
NPI:1063658730
Name:ELLINGBURG, HOLLY (MAMFT, LPC)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:ELLINGBURG
Suffix:
Gender:F
Credentials:MAMFT, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 I 55 N STE 293
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5966
Mailing Address - Country:US
Mailing Address - Phone:601-982-5943
Mailing Address - Fax:601-362-4089
Practice Address - Street 1:4500 I 55 N STE 293
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5966
Practice Address - Country:US
Practice Address - Phone:601-982-5943
Practice Address - Fax:601-362-4089
Is Sole Proprietor?:No
Enumeration Date:2008-12-30
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1409101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional