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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