Provider Demographics
NPI:1063818490
Name:ELLERY, RACHELLE (MS)
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:
Last Name:ELLERY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:RACHELLE
Other - Middle Name:
Other - Last Name:HUNTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1121
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0254
Mailing Address - Country:US
Mailing Address - Phone:541-672-2691
Mailing Address - Fax:833-299-8415
Practice Address - Street 1:548 SE JACKSON ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-4983
Practice Address - Country:US
Practice Address - Phone:541-672-2691
Practice Address - Fax:833-299-8415
Is Sole Proprietor?:No
Enumeration Date:2014-11-12
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF82840106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist