1124440367 NPI number — LINDA ELLIS, MA, LPC

Table of content: (NPI 1124440367)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124440367 NPI number — LINDA ELLIS, MA, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LINDA ELLIS, MA, LPC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124440367
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
255 STABLE GATE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLAIRSVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30512-8062
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-781-2661
Provider Business Mailing Address Fax Number:
706-781-2661

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
48 HARALSON PL
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
BLAIRSVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30512-3087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-781-2661
Provider Business Practice Location Address Fax Number:
706-781-2661
Provider Enumeration Date:
01/07/2014

Additional Information

Authorized Official

Authorized Official Last Name:
ELLIS
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
Authorized Official Title or Position:
LICENSED COUNSELOR
Authorized Official Telephone Number:
706-781-2661

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  1578 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 731631000 . This is a "MAGELLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 033901 . This is a "VALUE OPTIONS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 084833 . This is a "MHN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1151965 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 694416721-A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 033901 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 52492483-001 . This is a "BCBSGA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 289514654 . This is a "UNITED BEHAVIORAL HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6838713 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".




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