Provider Demographics
NPI:1871953000
Name:ELLERY, MEGAN (LPC)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:ELLERY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6549 TOWN CENTER DR
Mailing Address - Street 2:STE. A
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4824
Mailing Address - Country:US
Mailing Address - Phone:248-620-6400
Mailing Address - Fax:248-620-6405
Practice Address - Street 1:8150 OLD 13 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093
Practice Address - Country:US
Practice Address - Phone:586-825-9700
Practice Address - Fax:586-825-9701
Is Sole Proprietor?:No
Enumeration Date:2016-03-01
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017509101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional