Provider Demographics
NPI:1285358572
Name:MACDONALD, ELLEN ELIZABETH
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:ELIZABETH
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1986 WILLIAM WHITLEY RD
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:KY
Mailing Address - Zip Code:40484-8885
Mailing Address - Country:US
Mailing Address - Phone:702-480-9516
Mailing Address - Fax:
Practice Address - Street 1:7495 W AZURE DR STE 205
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-4416
Practice Address - Country:US
Practice Address - Phone:702-480-9516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-29
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCI5182101YM0800X
KY291274101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health