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General NPI Number Information
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NPI Number | 1528107158
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Entity Type | Individual
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Provider Name | MARINA J. ELLIS LCPC
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Gender | Female
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Dates
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Enumeration Date | 02/06/2007
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 427 N ARTHUR AVE STE B
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City | POCATELLO
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State | ID
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Zip | 83204-3006
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Country | US
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Telephone | 208-637-0334
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Fax | 208-237-9670
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Provider Business Mailing Address
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Address Line | PO BOX 5474
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City | CHUBBUCK
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State | ID
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Zip | 83202-0003
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Country | US
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Telephone | 208-637-0334
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Fax | 208-237-9670
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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 | LCPC303
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License Number State | ID
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