MEDICARE: ELLISE DANIELLE MILBURN LPC

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	PC011044	PA

General Provider Information

NPI Number	:	1568928620
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLISE DANIELLE MILBURN LPC

Provider Business Mailing Address
First Line	:	3148 DERRY RD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19154-2518
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3148 DERRY RD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19154-2518
Country	:	US
Telephone Number	:	215-584-7393
Fax Number	:

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

Provider Enumeration Date	:	02/13/2019
Last Update Date	:	10/18/2024

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