Healthcare Provider Details

I. General information

NPI: 1639610520
Provider Name (Legal Business Name): DANA M ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DANA M HARMEL

II. Dates (important events)

Enumeration Date: 03/13/2017
Last Update Date: 05/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 W GRAND AVE
BELOIT WI
53511-6259
US

IV. Provider business mailing address

3743 S MILTON SHOPIERE RD
JANESVILLE WI
53546-8616
US

V. Phone/Fax

Practice location:
  • Phone: 608-346-8315
  • Fax:
Mailing address:
  • Phone: 608-728-0086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: