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General NPI Number Information
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NPI Number | 1912522582
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Entity Type | Individual
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Provider Name | DORIAN ELLIS
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Gender | Male
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Dates
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Enumeration Date | 06/10/2020
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Last Update Date | 06/10/2020
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Provider Practice Location Address
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Address Line | 5470 LEMOYNE DR SW
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City | ATLANTA
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State | GA
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Zip | 30331-9206
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Country | US
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Telephone | 617-331-6966
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Fax |
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Provider Business Mailing Address
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Address Line | 3645 MARKETPLACE BLVD STE 130-171
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City | ATLANTA
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State | GA
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Zip | 30344-5747
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Country | US
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Telephone | 470-222-5354
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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 | 007688
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License Number State | GA
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