Provider Demographics
NPI:1083301840
Name:WALLER-ELLISON, REBECCA (MA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:WALLER-ELLISON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1119 SUGARTREE DR S
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-1867
Mailing Address - Country:US
Mailing Address - Phone:863-640-3220
Mailing Address - Fax:
Practice Address - Street 1:905 S MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-1033
Practice Address - Country:US
Practice Address - Phone:863-450-3626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH20732101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health