Provider Demographics
NPI:1114316692
Name:ROGERS, ELLIE (LPC)
Entity Type:Individual
Prefix:
First Name:ELLIE
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:ELLIE
Other - Middle Name:
Other - Last Name:FELLBAUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:1600 GLENVALLEY DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-1116
Mailing Address - Country:US
Mailing Address - Phone:210-844-9981
Mailing Address - Fax:303-432-5071
Practice Address - Street 1:1211 ALEXANDER AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-2421
Practice Address - Country:US
Practice Address - Phone:512-522-4285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-21
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
TX76240101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health