Provider Demographics
NPI:1912987744
Name:ELLIS, DAVID JEFFREY (LPC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JEFFREY
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318A E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAVELOCK
Mailing Address - State:NC
Mailing Address - Zip Code:28532-2214
Mailing Address - Country:US
Mailing Address - Phone:252-447-7764
Mailing Address - Fax:252-444-6800
Practice Address - Street 1:318A E MAIN ST
Practice Address - Street 2:
Practice Address - City:HAVELOCK
Practice Address - State:NC
Practice Address - Zip Code:28532-2214
Practice Address - Country:US
Practice Address - Phone:252-447-7764
Practice Address - Fax:252-444-6800
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4832101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC256439OtherCOMPSYCH PROVIDER
NC139NNOtherBC PROFESSIONAL COUNSELOR
NC361114OtherMHN PROVIDER
NC6102666Medicaid