Provider Demographics
NPI:1336982255
Name:ELLIS, NICOLE PETTIS
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:PETTIS
Last Name:ELLIS
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 1:1407 SUMMIT SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30350-2937
Mailing Address - Country:US
Mailing Address - Phone:850-567-8964
Mailing Address - Fax:
Practice Address - Street 1:270 HERITAGE WALK
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3875
Practice Address - Country:US
Practice Address - Phone:678-494-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)