Provider Demographics
NPI:1396850988
Name:ELLIS, AMY CAROL (LMHC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:CAROL
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5091 SAN MIGUEL ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583-5630
Mailing Address - Country:US
Mailing Address - Phone:850-261-9032
Mailing Address - Fax:850-994-6958
Practice Address - Street 1:5200 WOODBINE RD
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-8715
Practice Address - Country:US
Practice Address - Phone:850-261-9032
Practice Address - Fax:850-994-6958
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6475101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health