| Doctor Name: | MR. KERMIT J ELLISON |
| NPI Number: | 1013354463 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | 2482622 |
| Business Practice Address: | 1240 Bamburg Ct Hanover Park, IL - 601335243 |
| Business Phone Number: | 6303726599 |
| Business Fax Number: | 6303726697 |
| Mailing Address: | 1240 Bamburg Ct, HANOVER PARK |
| State: | IL |
| Postal Code: | 601335243 |
| Phone Number: | 6303726599 |
| Fax Number: | 6303726697 |
| NPI Enumeration Date: | 05/24/2013 |
| NPI Last Update Date: | 05/24/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YS0200X |
| License Number: | 2482622 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | IL |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | School |
| Taxonomy Definition: | |