Provider Demographics
NPI:1306070958
Name:ELLIS, ANGELA LESLIE (LPC)
Entity type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:LESLIE
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 1:2561 RAINOVER CT
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-2264
Mailing Address - Country:US
Mailing Address - Phone:404-288-3759
Mailing Address - Fax:
Practice Address - Street 1:100 CRESCENT CENTER PKWY
Practice Address - Street 2:SUITE 1290
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-7060
Practice Address - Country:US
Practice Address - Phone:770-621-0479
Practice Address - Fax:770-621-0466
Is Sole Proprietor?:No
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC005488101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional