Healthcare Provider Details

I. General information

NPI: 1992251136
Provider Name (Legal Business Name): EMILY ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 01/10/2023
Certification Date: 01/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3454 OAK ALLEY CT STE 400
TOLEDO OH
43606-1355
US

IV. Provider business mailing address

3454 OAK ALLEY CT STE 400
TOLEDO OH
43606-1355
US

V. Phone/Fax

Practice location:
  • Phone: 567-298-4070
  • Fax:
Mailing address:
  • Phone: 567-298-4070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.2204750
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberOH3150341
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: