Provider Demographics
NPI:1427454867
Name:THOMAS, ELLEN ALEXANDRA (PC-IT)
Entity type:Individual
Prefix:MISS
First Name:ELLEN
Middle Name:ALEXANDRA
Last Name:THOMAS
Suffix:
Gender:F
Credentials:PC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16275 W WISCONSIN AVE
Mailing Address - Street 2:APT 312
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005
Mailing Address - Country:US
Mailing Address - Phone:901-644-3910
Mailing Address - Fax:
Practice Address - Street 1:16275 W WISCONSIN AVE
Practice Address - Street 2:APT 312
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005
Practice Address - Country:US
Practice Address - Phone:901-644-3910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
WI2311-226101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor