Healthcare Provider Details

I. General information

NPI: 1922943489
Provider Name (Legal Business Name): LISA ELLIS LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 S RIDGEWOOD AVE # 206
DAYTONA BEACH FL
32114-4929
US

IV. Provider business mailing address

517 S RIDGEWOOD AVE # 206
DAYTONA BEACH FL
32114-4929
US

V. Phone/Fax

Practice location:
  • Phone: 407-391-5917
  • Fax:
Mailing address:
  • Phone: 407-391-5917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH17765
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: