Provider Demographics
NPI:1679232136
Name:ELLIS, ANNA (MA, LADC, LPCC)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MA, LADC, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18205 45TH AVE N STE D
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-4594
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1875 STATION PKWY NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-3319
Practice Address - Country:US
Practice Address - Phone:763-482-9598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-13
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305435101YA0400X
MN3115101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)