Provider Demographics
NPI:1700439403
Name:ELLIS, MARIAH ASHLEY (LADC, CADC II)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:ASHLEY
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LADC, CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 Q ST APT 72
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-3493
Mailing Address - Country:US
Mailing Address - Phone:218-205-6483
Mailing Address - Fax:
Practice Address - Street 1:1 SERENITY LN
Practice Address - Street 2:
Practice Address - City:COBURG
Practice Address - State:OR
Practice Address - Zip Code:97408-9350
Practice Address - Country:US
Practice Address - Phone:541-687-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305466101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)