Provider Demographics
NPI:1457023962
Name:ELLIS, REBECCA SUE
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUE
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 1:9 SCOTTSDALE AVENUE
Mailing Address - Street 2:
Mailing Address - City:LISBON FALLS
Mailing Address - State:ME
Mailing Address - Zip Code:04252
Mailing Address - Country:US
Mailing Address - Phone:207-200-3078
Mailing Address - Fax:
Practice Address - Street 1:153 PARK ROW
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011
Practice Address - Country:US
Practice Address - Phone:207-504-3587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-03
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC7415101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional