Healthcare Provider Details

I. General information

NPI: 1578290227
Provider Name (Legal Business Name): AMY LU ANN ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2022
Last Update Date: 08/03/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 N HIGHLAND AVE
AURORA IL
60506-1449
US

IV. Provider business mailing address

1820 S 25TH AVE
BROADVIEW IL
60155-3960
US

V. Phone/Fax

Practice location:
  • Phone: 630-906-7015
  • Fax:
Mailing address:
  • Phone: 708-681-0073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number101YM0800X
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: