Provider Demographics
NPI:1417635749
Name:ELLIS, OLIVIA KAY
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:KAY
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:948 ELM ST STE 2
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-2277
Mailing Address - Country:US
Mailing Address - Phone:270-266-1188
Mailing Address - Fax:
Practice Address - Street 1:948 ELM ST STE 2
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-2277
Practice Address - Country:US
Practice Address - Phone:270-266-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYNA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor