Healthcare Provider Details

I. General information

NPI: 1730346792
Provider Name (Legal Business Name): LESLIE ELAINE ELLIS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 EAGLE POINT DR
DALTON GA
30720-4941
US

IV. Provider business mailing address

2005 EAGLE POINT DR
DALTON GA
30720-4941
US

V. Phone/Fax

Practice location:
  • Phone: 727-365-8577
  • Fax:
Mailing address:
  • Phone: 727-365-8577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberGA3273
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: