Provider Demographics
NPI:1275994295
Name:ELLSOOS, LAURIE
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:ELLSOOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 S COCALICO RD
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:PA
Mailing Address - Zip Code:17517-9545
Mailing Address - Country:US
Mailing Address - Phone:717-606-7652
Mailing Address - Fax:717-336-4014
Practice Address - Street 1:400 W MAIN ST
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522-1760
Practice Address - Country:US
Practice Address - Phone:717-380-1219
Practice Address - Fax:717-336-4014
Is Sole Proprietor?:No
Enumeration Date:2016-03-18
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC008666101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional