Provider Demographics
NPI:1568406239
Name:ELLYSON, CATHERINE C (LCPC)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:C
Last Name:ELLYSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:KITTY
Other - Middle Name:
Other - Last Name:ELLYSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCPC
Mailing Address - Street 1:45 A ST
Mailing Address - Street 2:2W
Mailing Address - City:S PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2872
Mailing Address - Country:US
Mailing Address - Phone:207-899-9844
Mailing Address - Fax:
Practice Address - Street 1:95 EXCHANGE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-5037
Practice Address - Country:US
Practice Address - Phone:207-871-1000
Practice Address - Fax:207-773-0472
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068-0000646101YM0800X
MECC3038101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME100196OtherANTHEM