Provider Demographics
NPI:1962274662
Name:SHATTUCK, ELLIE VICTORIA (PCLC)
Entity type:Individual
Prefix:MRS
First Name:ELLIE
Middle Name:VICTORIA
Last Name:SHATTUCK
Suffix:
Gender:F
Credentials:PCLC
Other - Prefix:MS
Other - First Name:ELLIE
Other - Middle Name:VICTORIA
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:500 WESTGATE AVE
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-2503
Mailing Address - Country:US
Mailing Address - Phone:704-574-0383
Mailing Address - Fax:
Practice Address - Street 1:1970 STADIUM DR STE B
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-0623
Practice Address - Country:US
Practice Address - Phone:704-574-0383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-PCLC-LIC-48422101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health