Provider Demographics
NPI:1629008313
Name:ELLIS, GEERTINA H (HSP-PA, LPA)
Entity Type:Individual
Prefix:
First Name:GEERTINA
Middle Name:H
Last Name:ELLIS
Suffix:
Gender:F
Credentials:HSP-PA, LPA
Other - Prefix:DR
Other - First Name:GEERTINA
Other - Middle Name:
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EDD
Mailing Address - Street 1:5242 SUNDOWN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-3287
Mailing Address - Country:US
Mailing Address - Phone:910-578-3451
Mailing Address - Fax:910-487-0703
Practice Address - Street 1:5242 SUNDOWN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-3287
Practice Address - Country:US
Practice Address - Phone:910-670-9689
Practice Address - Fax:910-487-0703
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2167103T00000X
NCNC2167103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC84-1999514Medicaid