Provider Demographics
NPI:1104537380
Name:ELLIS, GENEVIEVE BRIENNE (LPC)
Entity type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:BRIENNE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 BROUGHTON DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-1815
Mailing Address - Country:US
Mailing Address - Phone:404-907-8044
Mailing Address - Fax:
Practice Address - Street 1:100 STONEFOREST DR STE 230
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-4903
Practice Address - Country:US
Practice Address - Phone:770-389-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-08
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC007904101Y00000X
GA014369101YP2500X
GALPC014369101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor