Provider Demographics
NPI:1205216314
Name:ELLIS, CHRISTINE (LMHC)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 ATLANTIC BLVD STE 161
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-3313
Mailing Address - Country:US
Mailing Address - Phone:904-515-2050
Mailing Address - Fax:
Practice Address - Street 1:4300 MARSH LANDING BLVD STE 204
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-1420
Practice Address - Country:US
Practice Address - Phone:904-515-2050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-03
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13237101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH13237OtherSTATE OF FLORIDA