Provider Demographics
NPI:1255378386
Name:ELLIS, MESHA LYGIA (PHD)
Entity type:Individual
Prefix:DR
First Name:MESHA
Middle Name:LYGIA
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2255 CUMBERLAND PARKWAY 500-140
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-4524
Mailing Address - Country:US
Mailing Address - Phone:678-538-6450
Mailing Address - Fax:404-478-8413
Practice Address - Street 1:2255 CUMBERLAND PARKWAY 500-140
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-4524
Practice Address - Country:US
Practice Address - Phone:678-538-6450
Practice Address - Fax:404-478-8413
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2020-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 20263103TC0700X
GAPSY003274103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent