MEDICARE: CAROLYN ILONA 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	MH6728	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588890677
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLYN ILONA ELLIS LMHC

Provider Business Mailing Address
First Line	:	2022 PONDEROSA AVE
Second Line	:
City	:	WINTER PARK
State	:	FL
Zip	:	32792-2064
Country	:	US
Telephone Number	:	407-538-7984
Fax Number	:

Provider Business Practice Location Address
First Line	:	3001 ALOMA AVE STE 214
Second Line	:
City	:	WINTER PARK
State	:	FL
Zip	:	32792-3752
Country	:	US
Telephone Number	:	407-538-7984
Fax Number	:

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

Provider Enumeration Date	:	06/03/2009
Last Update Date	:	06/03/2009

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