Healthcare Provider Details

I. General information

NPI: 1063558294
Provider Name (Legal Business Name): ELLEN HOMLONG PC, RD,LD,CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 12/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4641 FULTON DR NW
CANTON OH
44718-2384
US

IV. Provider business mailing address

2655 HARLAND DR
HUDSON OH
44236-3257
US

V. Phone/Fax

Practice location:
  • Phone: 330-433-6075
  • Fax:
Mailing address:
  • Phone: 234-380-5250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD4671
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.1300021
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: