Provider Demographics
NPI:1952073777
Name:ELLIS, MEREDITH JANE (APC, LPC)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:JANE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:APC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 PENINSULA CIR
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-6094
Mailing Address - Country:US
Mailing Address - Phone:678-832-7769
Mailing Address - Fax:
Practice Address - Street 1:5480 MCGINNIS VILLAGE PL STE 104
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-1746
Practice Address - Country:US
Practice Address - Phone:678-213-2194
Practice Address - Fax:678-922-7767
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-30
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC014567101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty