Provider Demographics
NPI:1891287066
Name:ELLIS-WHITE, MICKENSY LEIGH (MS, LCPC, NCC, MAC)
Entity Type:Individual
Prefix:MRS
First Name:MICKENSY
Middle Name:LEIGH
Last Name:ELLIS-WHITE
Suffix:
Gender:F
Credentials:MS, LCPC, NCC, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-5051
Mailing Address - Country:US
Mailing Address - Phone:765-893-1790
Mailing Address - Fax:
Practice Address - Street 1:1300 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-5051
Practice Address - Country:US
Practice Address - Phone:765-893-1790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-04
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X
IL180.009488101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health