Provider Demographics
NPI:1912039553
Name:LINDA ELLIS, MA, LPC, INC
Entity Type:Organization
Organization Name:LINDA ELLIS, MA, LPC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:706-781-2661
Mailing Address - Street 1:255 STABLE GATE DR
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-8062
Mailing Address - Country:US
Mailing Address - Phone:706-781-2661
Mailing Address - Fax:706-781-2661
Practice Address - Street 1:48 HARALSON PL
Practice Address - Street 2:# 3
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-3087
Practice Address - Country:US
Practice Address - Phone:706-781-2661
Practice Address - Fax:706-781-2661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC 1578101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA694416721AMedicaid
1326002379OtherINDIVIDUAL NPI