Provider Demographics
NPI:1699902775
Name:ELLIS, ANDREA (PC)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 N RIDGE RD E
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44055-3371
Mailing Address - Country:US
Mailing Address - Phone:440-260-6108
Mailing Address - Fax:440-240-0193
Practice Address - Street 1:1875 N RIDGE RD E
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44055-3371
Practice Address - Country:US
Practice Address - Phone:440-260-6108
Practice Address - Fax:440-240-0193
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.0700234.TEMP101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional