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General NPI Number Information
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NPI Number | 1700132099
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Entity Type | Organization
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Legal Business Name | NATHALIE ELLIS, LLC
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Dates
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Enumeration Date | 07/24/2012
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Last Update Date | 07/24/2012
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Provider Practice Location Address
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Address Line | 2855 CANDLER RD SUITE 9
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City | DECATUR
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State | GA
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Zip | 30034-1415
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Country | US
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Telephone | 678-732-7269
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Fax | 678-601-2928
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Provider Business Mailing Address
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Address Line | 3153 OXBRIDGE WAY
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City | LITHONIA
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State | GA
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Zip | 30038-2228
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Country | US
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Telephone | 678-732-7269
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Fax | 678-601-2928
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Authorized Official
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Title or Position | OWNER
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Name | NATHALIE D ELLIS
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Credential | LPC
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Telephone | 678-732-7269
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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 | LPC004352
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License Number State | GA
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