Provider Demographics
NPI:1104101245
Name:ELLISON, ELIZABETH LAURIE (MS LMFT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:LAURIE
Last Name:ELLISON
Suffix:
Gender:F
Credentials:MS LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 KESSEL CT STE 105
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-6227
Mailing Address - Country:US
Mailing Address - Phone:608-358-5111
Mailing Address - Fax:
Practice Address - Street 1:1320 MENDOTA ST STE 120
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53714-1060
Practice Address - Country:US
Practice Address - Phone:608-280-3106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI970-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist