Provider Demographics
NPI:1194153882
Name:ELLIS, ROBERT DANIEL JR (MA, LMFT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:DANIEL
Last Name:ELLIS
Suffix:JR
Gender:M
Credentials:MA, LMFT
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 858
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28082-0858
Mailing Address - Country:US
Mailing Address - Phone:704-224-8606
Mailing Address - Fax:
Practice Address - Street 1:715 PINE ST
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28081-4215
Practice Address - Country:US
Practice Address - Phone:704-224-8606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1539106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist