Provider Demographics
NPI:1942081872
Name:ELLIE PBC LLC
Entity Type:Organization
Organization Name:ELLIE PBC LLC
Other - Org Name:ELLIE MENTAL HEALTH - LAKE WORTH FLORIDA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:
Authorized Official - Last Name:MELNICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-855-2799
Mailing Address - Street 1:111 SE 1ST AVE APT 405
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33444-3796
Mailing Address - Country:US
Mailing Address - Phone:917-855-2799
Mailing Address - Fax:
Practice Address - Street 1:2290 10TH AVE N STE 601
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-6618
Practice Address - Country:US
Practice Address - Phone:917-855-2799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-06
Last Update Date:2023-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty