Provider Demographics
NPI:1922196187
Name:ELLISON, JAMES LUTHER (MS)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:LUTHER
Last Name:ELLISON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 BEACON HILL RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-5601
Mailing Address - Country:US
Mailing Address - Phone:803-799-9025
Mailing Address - Fax:803-931-8962
Practice Address - Street 1:33 BEACON HILL RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-5601
Practice Address - Country:US
Practice Address - Phone:803-799-9025
Practice Address - Fax:803-931-8962
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCWP9945103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities