Provider Demographics
NPI:1013636984
Name:DOSTER, ELLEN (LCMHCA)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:DOSTER
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 LAWNDALE DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-3030
Mailing Address - Country:US
Mailing Address - Phone:912-399-6015
Mailing Address - Fax:
Practice Address - Street 1:2422 REYNOLDA RD STE 6
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-4606
Practice Address - Country:US
Practice Address - Phone:336-794-6760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA17748101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health