Provider Demographics
NPI:1104153345
Name:ELLIS, ADRIENNE BENITA (PSYD)
Entity type:Individual
Prefix:DR
First Name:ADRIENNE
Middle Name:BENITA
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10805 SLIPPERY ELM CT
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-4097
Mailing Address - Country:US
Mailing Address - Phone:301-894-7421
Mailing Address - Fax:
Practice Address - Street 1:7801 OLD BRANCH AVE
Practice Address - Street 2:SUITE 212
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-1608
Practice Address - Country:US
Practice Address - Phone:301-856-8516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-09
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC3283101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional