Provider Demographics
NPI:1417189929
Name:ELLIS, KELLY PINNEY (MA, LPC, BCPC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:PINNEY
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MA, LPC, BCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 BROADWAY ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-1421
Mailing Address - Country:US
Mailing Address - Phone:269-214-1234
Mailing Address - Fax:269-872-3625
Practice Address - Street 1:404 BROADWAY ST
Practice Address - Street 2:SUITE B
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-1421
Practice Address - Country:US
Practice Address - Phone:269-214-1234
Practice Address - Fax:269-872-3625
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-17
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011487101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional