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General NPI Number Information
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NPI Number | 1649609546
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Entity Type | Individual
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Provider Name | T. NICOLE ELLIS LCSW
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Gender | Female
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Dates
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Enumeration Date | 11/01/2013
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Last Update Date | 01/28/2022
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Provider Practice Location Address
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Address Line | 780 PILOT HOUSE DR STE 100A
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City | NEWPORT NEWS
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State | VA
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Zip | 23606-4411
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Country | US
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Telephone | 757-593-1840
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Fax |
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Provider Business Mailing Address
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Address Line | 1819 OLDE BUCKINGHAM RD
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City | HAMPTON
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State | VA
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Zip | 23669-1916
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Country | US
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Telephone | 757-593-3953
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 0904008384
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License Number State | VA
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