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General NPI Number Information
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NPI Number | 1831741461
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Entity Type | Individual
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Provider Name | MARLYSSA RAE FILLMORE PHD
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Gender | Female
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Dates
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Enumeration Date | 07/13/2019
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Last Update Date | 10/23/2024
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Provider Practice Location Address
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Address Line | 4980 HUNTERS RUN
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City | COLUMBUS
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State | IN
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Zip | 47201-8499
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Country | US
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Telephone | 812-552-1499
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Fax |
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Provider Business Mailing Address
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Address Line | 4020 W GOELLER BLVD ELLIE MENTAL HEALTH
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City | COLUMBUS
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State | IN
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Zip | 47201-8499
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Country | US
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Telephone | 812-552-1499
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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 | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | 20043326A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | 10228724
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 20043326A
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License Number State | IN
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Taxonomy #4
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 20043326A
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License Number State | IN
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