Provider Demographics
NPI:1336795327
Name:ELLIS, AMANDA NICOLE (MPH MSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MPH MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3760 TRADEWINDS TER
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-6303
Mailing Address - Country:US
Mailing Address - Phone:941-447-8635
Mailing Address - Fax:
Practice Address - Street 1:128 N 2ND ST STE 202
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-6460
Practice Address - Country:US
Practice Address - Phone:615-348-5806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health