Provider Demographics
NPI:1831646066
Name:ELLISON, PETER (LPC, CCDP-D)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:ELLISON
Suffix:
Gender:M
Credentials:LPC, CCDP-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 FRANKLIN AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:PALMERTON
Mailing Address - State:PA
Mailing Address - Zip Code:18071-1521
Mailing Address - Country:US
Mailing Address - Phone:610-826-2320
Mailing Address - Fax:
Practice Address - Street 1:217 FRANKLIN AVE STE 106
Practice Address - Street 2:
Practice Address - City:PALMERTON
Practice Address - State:PA
Practice Address - Zip Code:18071-1521
Practice Address - Country:US
Practice Address - Phone:610-826-2320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC008997101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional