Provider Demographics
NPI:1447340666
Name:ELLIS, MARTHA BRUNER (EDS, LPC, NCC)
Entity type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:BRUNER
Last Name:ELLIS
Suffix:
Gender:F
Credentials:EDS, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:698 SILVER HILLS DR
Mailing Address - Street 2:
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36066-6184
Mailing Address - Country:US
Mailing Address - Phone:334-358-2455
Mailing Address - Fax:334-358-4909
Practice Address - Street 1:698 SILVER HILLS DR
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36066-6184
Practice Address - Country:US
Practice Address - Phone:334-358-2455
Practice Address - Fax:334-358-4909
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1835101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional