| Doctor Name: | MRS. KELLY PINNEY ELLIS |
| NPI Number: | 1417189929 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | MA, LPC, BCPC |
| License Number: | 6401011487 |
| Business Practice Address: | 404 Broadway St Suite B South Haven, MI - 490901421 |
| Business Phone Number: | 2692141234 |
| Business Fax Number: | 2698723625 |
| Mailing Address: | 404 Broadway St, Suite B SOUTH HAVEN |
| State: | MI |
| Postal Code: | 490901421 |
| Phone Number: | 2692141234 |
| Fax Number: | 2698723625 |
| NPI Enumeration Date: | 08/17/2009 |
| NPI Last Update Date: | 07/07/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YP2500X |
| License Number: | 6401011487 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Professional |
| Taxonomy Definition: | |