Provider Demographics
NPI:1396387064
Name:ELLISON, CHRISTOPHER BRUCE
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:BRUCE
Last Name:ELLISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 PLEASANT RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:WOODBINE
Mailing Address - State:KY
Mailing Address - Zip Code:40771-7538
Mailing Address - Country:US
Mailing Address - Phone:606-261-1722
Mailing Address - Fax:
Practice Address - Street 1:809 19TH STREET
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965
Practice Address - Country:US
Practice Address - Phone:606-248-3042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-14
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker