MEDICARE: CHRISTINE ELLIS LMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MH13237	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MH13237	OTHER	FL	STATE OF FLORIDA

General Provider Information

NPI Number	:	1205216314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE ELLIS LMHC

Provider Business Mailing Address
First Line	:	1015 ATLANTIC BLVD STE 161
Second Line	:
City	:	ATLANTIC BEACH
State	:	FL
Zip	:	32233-3313
Country	:	US
Telephone Number	:	904-515-2050
Fax Number	:

Provider Business Practice Location Address
First Line	:	4300 MARSH LANDING BLVD STE 204
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-1420
Country	:	US
Telephone Number	:	904-515-2050
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2015
Last Update Date	:	02/05/2021

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