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General NPI Number Information
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NPI Number | 1306070958
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Entity Type | Individual
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Provider Name | ANGELA LESLIE ELLIS LPC
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Gender | Female
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Dates
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Enumeration Date | 05/12/2009
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Last Update Date | 05/12/2009
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Provider Practice Location Address
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Address Line | 100 CRESCENT CENTER PKWY SUITE 1290
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City | TUCKER
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State | GA
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Zip | 30084-7060
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Country | US
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Telephone | 770-621-0479
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Fax | 770-621-0466
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Provider Business Mailing Address
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Address Line | 2561 RAINOVER CT
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City | DECATUR
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State | GA
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Zip | 30034-2264
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Country | US
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Telephone | 404-288-3759
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Fax |
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC005488
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License Number State | GA
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