Provider Demographics
NPI:1083282743
Name:HILLIARD, ELLEN ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:ELIZABETH
Last Name:HILLIARD
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ELLEN
Other - Middle Name:ELIZABETH
Other - Last Name:SMETHURST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1009 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4543
Mailing Address - Country:US
Mailing Address - Phone:434-996-8580
Mailing Address - Fax:434-996-8580
Practice Address - Street 1:1022 W 1ST ST STE 203
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-3642
Practice Address - Country:US
Practice Address - Phone:336-914-3038
Practice Address - Fax:336-914-3038
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15031101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty