Provider Demographics
NPI:1316346497
Name:ELLEDGE, JULIE (LMFT182)
Entity type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:
Last Name:ELLEDGE
Suffix:
Gender:F
Credentials:LMFT182
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 W PEARL AVE
Mailing Address - Street 2:3501
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-8406
Mailing Address - Country:US
Mailing Address - Phone:307-200-8777
Mailing Address - Fax:
Practice Address - Street 1:610 W BROADWAY AVE
Practice Address - Street 2:109
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8213
Practice Address - Country:US
Practice Address - Phone:307-200-8777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLMFT182106H00000X
CAMFC33952106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist