Provider Demographics
NPI:1275706012
Name:ELLISON, GINA R (LCPC)
Entity Type:Individual
Prefix:MS
First Name:GINA
Middle Name:R
Last Name:ELLISON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:MS
Other - First Name:GINA
Other - Middle Name:M
Other - Last Name:REYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:4600 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6106
Mailing Address - Country:US
Mailing Address - Phone:309-779-2031
Mailing Address - Fax:
Practice Address - Street 1:4600 3RD ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6106
Practice Address - Country:US
Practice Address - Phone:309-779-2031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor