Provider Demographics
NPI:1154609998
Name:ELLIS, NATHAN CODY (LCPC)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:CODY
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83653-0009
Mailing Address - Country:US
Mailing Address - Phone:208-461-7149
Mailing Address - Fax:208-467-3391
Practice Address - Street 1:703 S AMERICANA BLVD STE 150
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4976
Practice Address - Country:US
Practice Address - Phone:208-706-6375
Practice Address - Fax:208-706-6395
Is Sole Proprietor?:No
Enumeration Date:2011-07-27
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID4858101YA0400X, 101YM0800X, 101Y00000X, 101YP2500X, 102L00000X
IDLCPC-7528101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1091972OtherNATIONAL BOARD OF CERTIFIED COUNSELORS INC
1091972OtherNATIONAL BOARD FOR CERTIFIED COUNSELORS INC