Provider Demographics
NPI:1609505213
Name:ELLIE OF MARYLAND LLC
Entity Type:Organization
Organization Name:ELLIE OF MARYLAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:STAMPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-336-9745
Mailing Address - Street 1:227 PEGASUS CT
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-1145
Mailing Address - Country:US
Mailing Address - Phone:443-336-9745
Mailing Address - Fax:
Practice Address - Street 1:900 BESTGATE RD STE 210
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7922
Practice Address - Country:US
Practice Address - Phone:443-336-9745
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-08
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty