Provider Demographics
NPI:1639610520
Name:ELLIS, DANA M
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:M
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:M
Other - Last Name:HARMEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3743 S MILTON SHOPIERE RD
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-8616
Mailing Address - Country:US
Mailing Address - Phone:608-728-0086
Mailing Address - Fax:
Practice Address - Street 1:136 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-6259
Practice Address - Country:US
Practice Address - Phone:608-346-8315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-13
Last Update Date:2018-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional