Provider Demographics
NPI:1912670324
Name:ELLIS, SELENA (LMFT)
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16227 WOODLAWN ACRES AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-5655
Mailing Address - Country:US
Mailing Address - Phone:817-240-4734
Mailing Address - Fax:
Practice Address - Street 1:10500 SAM RUSHING RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-2000
Practice Address - Country:US
Practice Address - Phone:225-435-9602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1341106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist