Healthcare Provider Details

I. General information

NPI: 1669212890
Provider Name (Legal Business Name): MISTY ROBINSON ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2024
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2554 LEWISVILLE CLEMMONS RD STE 112
CLEMMONS NC
27012-9927
US

IV. Provider business mailing address

PO BOX 14121
AUGUSTA GA
30919-0121
US

V. Phone/Fax

Practice location:
  • Phone: 336-283-2510
  • Fax:
Mailing address:
  • Phone: 440-574-3944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP020742
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: