Provider Demographics
NPI:1588890677
Name:ELLIS, CAROLYN ILONA (LMHC)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ILONA
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2022 PONDEROSA AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-2064
Mailing Address - Country:US
Mailing Address - Phone:407-538-7984
Mailing Address - Fax:
Practice Address - Street 1:3001 ALOMA AVE STE 214
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3752
Practice Address - Country:US
Practice Address - Phone:407-538-7984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6728101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL763805100Medicaid