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Organization
ELLIE MAIN LINE LLC
Active
Organization
ELLIE MAIN LINE LLC
Active
Other names
Ellie Mental Health
Organization subpart
No
Provider details
NPI number
Authorized official
KRISTIN DUTKA (OWNER)
(910) 515-1340
Entity
Organization
Contact information
Practice address
1200 ATWATER DR STE 130, MALVERN, PA 19355-8782
(610) 646-1851
(484) 355-5181
Mailing address
392 MERLIN RD, PHOENIXVILLE, PA 19460-2109
(910) 515-1340
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
—
—
101YP2500X
Professional Counselor
—
—
103T00000X
Psychologist
—
—
1041C0700X
Clinical Social Worker
—
—
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
Other
Enumeration date
06/07/2023
Last updated
04/04/2024
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