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General NPI Number Information
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NPI Number | 1053478503
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Entity Type | Individual
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Provider Name | ELIZABETH MYRNA ELLIS PH.D.
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Gender | Female
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Dates
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Enumeration Date | 01/03/2007
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Last Update Date | 08/07/2023
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Provider Practice Location Address
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Address Line | 801 AMSTERDAM AVE NE
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City | ATLANTA
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State | GA
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Zip | 30306-3403
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Country | US
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Telephone | 770-337-9446
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Fax | 770-476-0377
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Provider Business Mailing Address
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Address Line | 801 AMSTERDAM AVE NE
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City | ATLANTA
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State | GA
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Zip | 30306-3403
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Country | US
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Telephone | 770-337-9446
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Fax | 770-476-0377
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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 | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 521
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License Number State | GA
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