Provider Demographics
NPI:1205025079
Name:ELLEN, KIM (MA, LPC)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:
Last Name:ELLEN
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2563 CROQUET DR UNIT 7
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-5179
Mailing Address - Country:US
Mailing Address - Phone:910-338-8251
Mailing Address - Fax:
Practice Address - Street 1:615 SHIPYARD BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-6431
Practice Address - Country:US
Practice Address - Phone:910-343-0145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401009255101Y00000X
NC7567101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)