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
State | License ID | Taxonomies |
---|---|---|
KY | 253581 | 1041C0700X |
KY | 243469 | 101YA0400X |
CA | 127570 | 1041C0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
KY | 7100567210 | Medicaid |