Provider Demographics
NPI:1851029243
Name:ELLIE MENTAL HEALTH OF ESTERO
Entity Type:Organization
Organization Name:ELLIE MENTAL HEALTH OF ESTERO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:
Authorized Official - Last Name:SILVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-432-4636
Mailing Address - Street 1:4421 TAMARIND WAY
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-9685
Mailing Address - Country:US
Mailing Address - Phone:908-432-4636
Mailing Address - Fax:
Practice Address - Street 1:22904 LYDEN DR STE 104
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-7048
Practice Address - Country:US
Practice Address - Phone:908-432-4636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-12
Last Update Date:2024-01-05
Deactivation Date:2023-08-05
Deactivation Code:
Reactivation Date:2023-08-24
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty