Provider Demographics
NPI:1588906242
Name:ELLEN, KRISTINA NICOLE (LPCA)
Entity type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:NICOLE
Last Name:ELLEN
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 VILLAGE RD SW
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SHALLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28470-3448
Mailing Address - Country:US
Mailing Address - Phone:910-754-2273
Mailing Address - Fax:910-754-2254
Practice Address - Street 1:712 VILLAGE RD SW
Practice Address - Street 2:SUITE 106
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-3448
Practice Address - Country:US
Practice Address - Phone:910-754-2273
Practice Address - Fax:910-754-2254
Is Sole Proprietor?:No
Enumeration Date:2013-03-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA10093101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)