Provider Demographics
NPI:1679902316
Name:ELLIS, KATHLEEN (PHD, LADC, LPC)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PHD, LADC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 ROSELUND HILL RD
Mailing Address - Street 2:
Mailing Address - City:UNCASVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06382-2115
Mailing Address - Country:US
Mailing Address - Phone:860-848-9214
Mailing Address - Fax:
Practice Address - Street 1:65 ROSELUND HILL RD
Practice Address - Street 2:
Practice Address - City:UNCASVILLE
Practice Address - State:CT
Practice Address - Zip Code:06382-2115
Practice Address - Country:US
Practice Address - Phone:860-848-9214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000903101YA0400X
CT002541101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional