Healthcare Provider Details

I. General information

NPI: 1851029243
Provider Name (Legal Business Name): ELLIE MENTAL HEALTH OF ESTERO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2022
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date: 08/05/2023
Reactivation Date: 08/24/2023

III. Provider practice location address

22904 LYDEN DR STE 104
ESTERO FL
33928-7048
US

IV. Provider business mailing address

22904 LYDEN DR UNIT 104
ESTERO FL
33928-7048
US

V. Phone/Fax

Practice location:
  • Phone: 908-432-4636
  • Fax:
Mailing address:
  • Phone: 908-432-4636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MARCUS SILVA
Title or Position: MANAGING MEMBER
Credential:
Phone: 908-432-4636