Provider Demographics
NPI:1326309535
Name:ELLISON, CYNTHIA SHERRON (LPC)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:SHERRON
Last Name:ELLISON
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 1:2909 PHEASANT WAY
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-6125
Mailing Address - Country:US
Mailing Address - Phone:757-484-1743
Mailing Address - Fax:
Practice Address - Street 1:281 INDEPENDENCE BLVD
Practice Address - Street 2:SUITE 326
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-2986
Practice Address - Country:US
Practice Address - Phone:757-490-0377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005219103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007770359Medicaid
VANPPOOOOtherUPIN
VA680000167OtherMEDICARE