Provider Demographics
NPI:1023683216
Name:ELLISON-MOORE, FARRAH R (LPC, NCC)
Entity type:Individual
Prefix:
First Name:FARRAH
Middle Name:R
Last Name:ELLISON-MOORE
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18434 CLYDE RD
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-3014
Mailing Address - Country:US
Mailing Address - Phone:773-368-4878
Mailing Address - Fax:
Practice Address - Street 1:18161 MORRIS AVE
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2108
Practice Address - Country:US
Practice Address - Phone:773-368-4878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-21
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180015717101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional