Provider Demographics
NPI:1982267308
Name:ELLINGSEN, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ELLINGSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 12TH AVE S APT 522
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-6619
Mailing Address - Country:US
Mailing Address - Phone:760-579-2303
Mailing Address - Fax:
Practice Address - Street 1:600 12TH AVE S APT 522
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-6619
Practice Address - Country:US
Practice Address - Phone:760-579-2303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-22
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1266106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist