Provider Demographics
NPI:1164178588
Name:ELLIS, MIA (LCPC)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5116 DORSEY HALL DR
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-7871
Mailing Address - Country:US
Mailing Address - Phone:443-745-8062
Mailing Address - Fax:
Practice Address - Street 1:5116 DORSEY HALL DR
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-7871
Practice Address - Country:US
Practice Address - Phone:443-745-8062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-24
Last Update Date:2025-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC14726101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health