Provider Demographics
NPI:1023668134
Name:ETTMAN, ELLIE STACEY (LPC)
Entity type:Individual
Prefix:MRS
First Name:ELLIE
Middle Name:STACEY
Last Name:ETTMAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 ALMOND CT
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19444-2500
Mailing Address - Country:US
Mailing Address - Phone:215-327-3791
Mailing Address - Fax:
Practice Address - Street 1:1364 WELSH RD
Practice Address - Street 2:
Practice Address - City:NORTH WALES
Practice Address - State:PA
Practice Address - Zip Code:19454-1913
Practice Address - Country:US
Practice Address - Phone:215-327-3791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC006011101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional