Provider Demographics
NPI:1881936284
Name:HOLBROOK, ELLEN ELIZABETH (MA)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:ELIZABETH
Last Name:HOLBROOK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3732 LAKESIDE DR STE 202
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-4519
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3732 LAKESIDE DR STE 202
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-4519
Practice Address - Country:US
Practice Address - Phone:320-905-4345
Practice Address - Fax:507-299-0436
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-23
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00843101YP2500X
NVCP0150101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100553454Medicaid