Healthcare Provider Details

I. General information

NPI: 1104537380
Provider Name (Legal Business Name): GENEVIEVE BRIENNE ELLIS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2022
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 STONEFOREST DR STE 230
WOODSTOCK GA
30189-4903
US

IV. Provider business mailing address

518 BROUGHTON DR
CANTON GA
30114-1815
US

V. Phone/Fax

Practice location:
  • Phone: 770-389-8100
  • Fax:
Mailing address:
  • Phone: 404-907-8044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberAPC007904
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number014369
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC014369
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: