Provider Demographics
NPI:1427782010
Name:ELLIE, BRITTANY LYNN LOUISE
Entity type:Individual
Prefix:
First Name:BRITTANY LYNN
Middle Name:LOUISE
Last Name:ELLIE
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:N5367 MAYFLOWER RD
Mailing Address - Street 2:
Mailing Address - City:SHIOCTON
Mailing Address - State:WI
Mailing Address - Zip Code:54170-8934
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:N5367 MAYFLOWER RD
Practice Address - Street 2:
Practice Address - City:SHIOCTON
Practice Address - State:WI
Practice Address - Zip Code:54170-8934
Practice Address - Country:US
Practice Address - Phone:877-300-9101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5385-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health