Provider Demographics
NPI:1639666704
Name:ELLIS, AMBERLY (LPC)
Entity Type:Individual
Prefix:
First Name:AMBERLY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1247 TUSCANY DR.
Mailing Address - Street 2:B-1
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517
Mailing Address - Country:US
Mailing Address - Phone:678-465-8665
Mailing Address - Fax:
Practice Address - Street 1:1247 TUSCANY DR.
Practice Address - Street 2:SUITE B-1
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517
Practice Address - Country:US
Practice Address - Phone:678-465-8665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-15
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC009083101YM0800X
GALPC011633101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health