Basic Information
| Provider Information | |||||||||
| NPI: | 1164769964 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLISON | ||||||||
| FirstName: | COREY | ||||||||
| MiddleName: | JASON | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 145 SCALEYBARK RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282092687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046083886 | ||||||||
| FaxNumber: | 7045366030 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 SCALEYBARK RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282092687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046083886 | ||||||||
| FaxNumber: | 7045366030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2013 | ||||||||
| LastUpdateDate: | 01/14/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | A9913 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.