Provider Demographics
NPI:1780363820
Name:ELLIS, GAIL LYNN (CPSS/ FCPSS)
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:LYNN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:CPSS/ FCPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 PINEHURST DR APT 4
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-2728
Mailing Address - Country:US
Mailing Address - Phone:859-652-4550
Mailing Address - Fax:
Practice Address - Street 1:1629 MADISON AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-3317
Practice Address - Country:US
Practice Address - Phone:859-814-8022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist