Provider Demographics
NPI:1962161786
Name:ELLIS, CRYSTAL MONIQUE (LPC)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MONIQUE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 LAKEFIELD MEWS CT APT L
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23231-4185
Mailing Address - Country:US
Mailing Address - Phone:757-329-8037
Mailing Address - Fax:
Practice Address - Street 1:5402 GLENSIDE DR STE D
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23228-3994
Practice Address - Country:US
Practice Address - Phone:757-329-8037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701010977101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional