Provider Demographics
NPI:1164769964
Name:ELLISON, COREY JASON (LPCA)
Entity Type:Individual
Prefix:MR
First Name:COREY
Middle Name:JASON
Last Name:ELLISON
Suffix:
Gender:M
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 SCALEYBARK RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2687
Mailing Address - Country:US
Mailing Address - Phone:704-608-3886
Mailing Address - Fax:704-536-6030
Practice Address - Street 1:145 SCALEYBARK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-2687
Practice Address - Country:US
Practice Address - Phone:704-608-3886
Practice Address - Fax:704-536-6030
Is Sole Proprietor?:No
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA9913101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health