MEDICARE: CHRISTINE ELLIS LPC LICDC

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	101YS0200X	School Counselor	C.2002664-TRNE	OH
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	LICDC.162252	OH
3	101YA0400X	Addiction (Substance Use Disorder) Counselor	CDCA.168065	OH
4	101YP2500X	Professional Counselor	C.2103639	OH

General Provider Information

NPI Number	:	1992262653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE ELLIS LPC LICDC

Provider Business Mailing Address
First Line	:	1141 ARBOR SPRINGS DR
Second Line	:
City	:	HAMILTON
State	:	OH
Zip	:	45013-1865
Country	:	US
Telephone Number	:	513-919-6338
Fax Number	:	513-919-6338

Provider Business Practice Location Address
First Line	:	1141 ARBOR SPRINGS DR
Second Line	:
City	:	HAMILTON
State	:	OH
Zip	:	45013-1865
Country	:	US
Telephone Number	:	513-919-6338
Fax Number	:

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

Provider Enumeration Date	:	02/28/2019
Last Update Date	:	07/22/2022

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