Provider Demographics
NPI:1093169369
Name:ELLIS, SHERELL (LPC; BCBA)
Entity Type:Individual
Prefix:
First Name:SHERELL
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LPC; BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2932 AYLESBURY DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-0628
Mailing Address - Country:US
Mailing Address - Phone:706-589-8255
Mailing Address - Fax:
Practice Address - Street 1:2100 CENTRAL AVE STE D1
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-6709
Practice Address - Country:US
Practice Address - Phone:706-843-6241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-22
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008669101YP2500X
GA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst