Provider Demographics
NPI:1801414578
Name:ELLIS, KEVA (LPC)
Entity Type:Individual
Prefix:MS
First Name:KEVA
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 1:6815 W FAYETTEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-2528
Mailing Address - Country:US
Mailing Address - Phone:907-984-2477
Mailing Address - Fax:
Practice Address - Street 1:6815 W FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296-2528
Practice Address - Country:US
Practice Address - Phone:281-236-6762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-09
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010433101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty