Provider Demographics
NPI:1649609546
Name:ELLIS, T. NICOLE (LCSW)
Entity type:Individual
Prefix:MS
First Name:T. NICOLE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 OLDE BUCKINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23669-1916
Mailing Address - Country:US
Mailing Address - Phone:757-593-3953
Mailing Address - Fax:
Practice Address - Street 1:780 PILOT HOUSE DR STE 100A
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4411
Practice Address - Country:US
Practice Address - Phone:757-593-1840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040083841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical