Provider Demographics
NPI:1326002379
Name:ELLIS, LINDA (LPC)
Entity Type:Individual
Prefix:MS
First Name:LINDA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 STABLE GATE DR
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-8062
Mailing Address - Country:US
Mailing Address - Phone:706-781-2661
Mailing Address - Fax:706-781-2661
Practice Address - Street 1:48 HARALSON PL
Practice Address - Street 2:SUITE 3
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-3087
Practice Address - Country:US
Practice Address - Phone:706-781-2661
Practice Address - Fax:706-781-2661
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC1578101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
033901OtherVALUE OPTIONS
GA52492483-001OtherBLUECROSS/BLUE SHIELD