Healthcare Provider Details

I. General information

NPI: 1619791845
Provider Name (Legal Business Name): CONNIE FAYE ELLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CONNIE FAYE ELLER LPC

II. Dates (important events)

Enumeration Date: 11/13/2024
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 DOGWOOD KNL
BOONE NC
28607-8135
US

IV. Provider business mailing address

409 DOGWOOD KNL
BOONE NC
28607-8135
US

V. Phone/Fax

Practice location:
  • Phone: 276-696-4336
  • Fax:
Mailing address:
  • Phone: 276-696-4336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701015636
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: