Healthcare Provider Details

I. General information

NPI: 1396850988
Provider Name (Legal Business Name): AMY CAROL ELLIS L.M.H.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 WOODBINE RD
PACE FL
32571-8715
US

IV. Provider business mailing address

5091 SAN MIGUEL ST
MILTON FL
32583-5630
US

V. Phone/Fax

Practice location:
  • Phone: 850-261-9032
  • Fax: 850-994-6958
Mailing address:
  • Phone: 850-261-9032
  • Fax: 850-994-6958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH6475
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: