Provider Demographics
NPI:1851461917
Name:ELLIS, MATTISON LANIER (LPC)
Entity type:Individual
Prefix:
First Name:MATTISON
Middle Name:LANIER
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8829 CENTRE ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-2610
Mailing Address - Country:US
Mailing Address - Phone:662-280-6777
Mailing Address - Fax:662-280-6775
Practice Address - Street 1:8829 CENTRE ST
Practice Address - Street 2:SUITE 105
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-2610
Practice Address - Country:US
Practice Address - Phone:662-280-6777
Practice Address - Fax:662-280-6775
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1112101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional