Provider Demographics
NPI:1164174645
Name:ELLIE, ANTHONY (LPC, NBCC, MA)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:ELLIE
Suffix:
Gender:M
Credentials:LPC, NBCC, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2209 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-4281
Mailing Address - Country:US
Mailing Address - Phone:920-892-7606
Mailing Address - Fax:
Practice Address - Street 1:2209 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-4281
Practice Address - Country:US
Practice Address - Phone:920-892-7606
Practice Address - Fax:920-449-4247
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-25
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10475-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional