Provider Demographics
NPI:1558138198
Name:ELLISON-HINES, PHILIP (LMFTA)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:ELLISON-HINES
Suffix:
Gender:M
Credentials:LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11650 OLIO RD STE 1000-191
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-7619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 S PENDLETON AVE STE 212
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:IN
Practice Address - Zip Code:46064-1189
Practice Address - Country:US
Practice Address - Phone:317-813-9064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN85000536A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist