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NPI Code Detail

MEDICARE: AMY C. ELLIS

MEDICARE: AMY C. ELLIS
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
1101YM0800XMental Health CounselorMH6475FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MH6475OTHERFLSTATE LICENSE

General Provider Information

NPI Number : 1841714458
Entity Type Code : Organization
Provider Name (Legal Business Name) : AMY C. ELLIS
Provider Business Mailing Address
First Line : 5170 ANNIE RUTH ST
Second Line :
City : MILTON
State : FL
Zip : 32570-8153
Country : US
Telephone Number : 850-261-9032
Fax Number : 850-243-8529
Provider Business Practice Location Address
First Line : 124 E MIRACLE STRIP PKWY STE 602
Second Line :
City : MARY ESTHER
State : FL
Zip : 32569-1991
Country : US
Telephone Number : 850-243-8529
Fax Number : 850-243-8529
Authorized Official
Title or Position : LMHC
Name : AMY ELLIS
Credential :
Telephone Number : 850-243-7035
Provider Enumeration Date : 07/26/2017
Last Update Date : 06/16/2018

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1649629833 — MICHEAL VILLANUEVA
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Practice Location Address:
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