Healthcare Provider Details

I. General information

NPI: 1841866886
Provider Name (Legal Business Name): BETHANY LYNN ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2021
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 E GORDON ST
BEL AIR MD
21014-2916
US

IV. Provider business mailing address

102 HERITAGE WAY NE
LEESBURG VA
20176-4544
US

V. Phone/Fax

Practice location:
  • Phone: 410-366-1980
  • Fax:
Mailing address:
  • Phone: 703-771-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0701015002
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC17226
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: