Provider Demographics
NPI:1447727185
Name:ELLISTON, REBECCA LEE (LCSW, LCADC)
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:LEE
Last Name:ELLISTON
Suffix:
Gender:F
Credentials:LCSW, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 W 5TH ST STE 219
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-1293
Mailing Address - Country:US
Mailing Address - Phone:859-292-4144
Mailing Address - Fax:
Practice Address - Street 1:525 W 5TH ST STE 219
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-1293
Practice Address - Country:US
Practice Address - Phone:859-292-4144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2535811041C0700X
KY243469101YA0400X
CA1275701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100567210Medicaid