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General NPI Number Information
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NPI Number | 1013354463
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Entity Type | Individual
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Provider Name | MR. KERMIT J ELLISON
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Gender | Male
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Dates
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Enumeration Date | 05/24/2013
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Last Update Date | 05/24/2013
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Provider Practice Location Address
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Address Line | 1240 BAMBURG CT
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City | HANOVER PARK
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State | IL
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Zip | 60133-5243
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Country | US
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Telephone | 630-372-6599
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Fax | 630-372-6697
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Provider Business Mailing Address
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Address Line | 1240 BAMBURG CT
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City | HANOVER PARK
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State | IL
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Zip | 60133-5243
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Country | US
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Telephone | 630-372-6599
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Fax | 630-372-6697
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 180006226
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 101YS0200X
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Taxonomy Name | School Counselor
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License Number | 2482622
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License Number State | IL
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