Provider Demographics
NPI:1093208894
Name:ELLIS, SOPHIE (EDS)
Entity Type:Individual
Prefix:
First Name:SOPHIE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 RAVEN RD
Mailing Address - Street 2:
Mailing Address - City:HANAHAN
Mailing Address - State:SC
Mailing Address - Zip Code:29410-8509
Mailing Address - Country:US
Mailing Address - Phone:843-813-3566
Mailing Address - Fax:
Practice Address - Street 1:9217 UNIVERSITY BLVD STE C1A
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9147
Practice Address - Country:US
Practice Address - Phone:843-619-7989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC227408103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool