| Doctor Name: | NICOLE RENEE ELLIS |
| NPI Number: | 1164580106 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LPCA |
| License Number: | KY-0442 |
| Business Practice Address: | 1072 S Dixie Blvd Radcliff, KY - 401601103 |
| Business Phone Number: | 2703518166 |
| Business Fax Number: | 2703518322 |
| Mailing Address: | 339 Madison Dr, ELIZABETHTOWN |
| State: | KY |
| Postal Code: | 427012167 |
| Phone Number: | 2707652605 |
| Fax Number: | 2702348572 |
| NPI Enumeration Date: | 12/04/2006 |
| NPI Last Update Date: | 03/29/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YP2500X |
| License Number: | KY-0442 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | KY |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Professional |
| Taxonomy Definition: | |