Healthcare Provider Details

I. General information

NPI: 1154110559
Provider Name (Legal Business Name): ELLISEN HERNDON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2025
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 GEORGIA AVE SE STE 206
ATLANTA GA
30312-3000
US

IV. Provider business mailing address

250 GEORGIA AVE SE STE 206
ATLANTA GA
30312-3000
US

V. Phone/Fax

Practice location:
  • Phone: 404-653-0374
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: