Provider Demographics
NPI:1811376429
Name:ELLIS, JOSHUA KYLE (LPC)
Entity Type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:KYLE
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:500 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-4730
Mailing Address - Country:US
Mailing Address - Phone:912-253-8003
Mailing Address - Fax:912-916-0300
Practice Address - Street 1:500 JACKSON ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-4730
Practice Address - Country:US
Practice Address - Phone:912-253-8003
Practice Address - Fax:912-916-0300
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008312101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional