Provider Demographics
NPI:1124440367
Name:LINDA ELLIS, MA, LPC
Entity type:Organization
Organization Name:LINDA ELLIS, MA, LPC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSED COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:706-781-2661
Mailing Address - Street 1:255 STABLE GATE DR
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-8062
Mailing Address - Country:US
Mailing Address - Phone:706-781-2661
Mailing Address - Fax:706-781-2661
Practice Address - Street 1:48 HARALSON PL
Practice Address - Street 2:SUITE 3
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-3087
Practice Address - Country:US
Practice Address - Phone:706-781-2661
Practice Address - Fax:706-781-2661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1578101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
731631000OtherMAGELLAN
033901OtherVALUE OPTIONS
084833OtherMHN
1151965OtherCAQH
GA694416721-AMedicaid
033901OtherTRICARE
GA52492483-001OtherBCBSGA
289514654OtherUNITED BEHAVIORAL HEALTH
6838713OtherCIGNA