Provider Demographics
NPI:1922621051
Name:ELLIS, ANDREA (LGPC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13115 LARCHDALE RD APT 12
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-1753
Mailing Address - Country:US
Mailing Address - Phone:240-595-0892
Mailing Address - Fax:
Practice Address - Street 1:1110 BENFIELD BLVD
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-2639
Practice Address - Country:US
Practice Address - Phone:410-756-0035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-23
Last Update Date:2020-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP10366101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health