Provider Demographics
NPI:1346677077
Name:ELLIS, ALICIA MICHELLE (EDD, LPC-MHSP)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:MICHELLE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:EDD, LPC-MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10543 CEDAR GROVE RD
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-6525
Mailing Address - Country:US
Mailing Address - Phone:615-905-6321
Mailing Address - Fax:
Practice Address - Street 1:10543 CEDAR GROVE RD
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-6525
Practice Address - Country:US
Practice Address - Phone:615-905-6321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-26
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2938101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ034586Medicaid