Provider Demographics
NPI:1164580106
Name:ELLIS, NICOLE RENEE (LPCC-S, NCC)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:RENEE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LPCC-S, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 CHRISTINE WAY
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701
Mailing Address - Country:US
Mailing Address - Phone:270-312-2877
Mailing Address - Fax:
Practice Address - Street 1:108 CHRISTINE WAY
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-9681
Practice Address - Country:US
Practice Address - Phone:270-312-2877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY103828101YP2500X
KYKY-0442101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30605018Medicaid
KY000000498778OtherANTHEM