Provider Demographics
NPI:1730427063
Name:ELLISON, MARK (LAMFT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ELLISON
Suffix:
Gender:M
Credentials:LAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 DALLAS HWY SW
Mailing Address - Street 2:SUITE 310
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-2597
Mailing Address - Country:US
Mailing Address - Phone:770-856-8393
Mailing Address - Fax:
Practice Address - Street 1:2655 DALLAS HWY SW
Practice Address - Street 2:SUITE 310
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-2597
Practice Address - Country:US
Practice Address - Phone:770-856-8393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-22
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAMFT000182106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist