Provider Demographics
NPI:1467600098
Name:ELLISON, ANDREW DELWYN (MS, LMFT)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:DELWYN
Last Name:ELLISON
Suffix:
Gender:M
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02909-1102
Mailing Address - Country:US
Mailing Address - Phone:401-996-7886
Mailing Address - Fax:
Practice Address - Street 1:1445 WAMPANOAG TRAIL UNIT 202
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915
Practice Address - Country:US
Practice Address - Phone:401-437-4116
Practice Address - Fax:401-433-0367
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIAE83731Medicaid