Healthcare Provider Details

I. General information

NPI: 1164174645
Provider Name (Legal Business Name): ANTHONY ELLIE LPC, NBCC, MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2022
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2209 EASTERN AVE
PLYMOUTH WI
53073-4281
US

IV. Provider business mailing address

2209 EASTERN AVE
PLYMOUTH WI
53073-4281
US

V. Phone/Fax

Practice location:
  • Phone: 920-892-7606
  • Fax: 920-449-4247
Mailing address:
  • Phone: 920-892-7606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10475-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: