Provider Demographics
NPI:1629678735
Name:ELLZEY, STEPHANIE (MA, NCC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:ELLZEY
Suffix:
Gender:F
Credentials:MA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5705 LYNNHAVEN PKWY APT 219
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-9152
Mailing Address - Country:US
Mailing Address - Phone:985-264-8208
Mailing Address - Fax:
Practice Address - Street 1:4169 VIRGINIA BEACH BLVD STE 150
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1783
Practice Address - Country:US
Practice Address - Phone:757-663-7404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704013309101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health