Provider Demographics
NPI:1184337941
Name:ELLISADDIE, MONIFA (LMFT)
Entity type:Individual
Prefix:
First Name:MONIFA
Middle Name:
Last Name:ELLISADDIE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:MONIFA
Other - Middle Name:
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1012 BATTERSEA PL
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-2077
Mailing Address - Country:US
Mailing Address - Phone:908-644-4830
Mailing Address - Fax:
Practice Address - Street 1:1012 BATTERSEA PL
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248-2077
Practice Address - Country:US
Practice Address - Phone:818-925-0569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-26
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA132372106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist