| Ellie Mental Health Ponte Vedra | |
|
1102 A1a N Ste 203 Ponte Vedra FL 32082-4098 | |
| (904) 903-6375 | |
| Not Available |
| Full Name | Ellie Mental Health Ponte Vedra |
|---|---|
| Speciality | Marriage & Family Therapist |
| Location | 1102 A1a N Ste 203, Ponte Vedra, Florida |
| Authorized Official Name and Position | Ansh Grover (COO) |
| Authorized Official Contact | 9049036375 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Ellie Mental Health Ponte Vedra 1102 A1a N Ste 203 Ponte Vedra Beach FL 32082-4098 Ph: (904) 903-6375 | Ellie Mental Health Ponte Vedra 1102 A1a N Ste 203 Ponte Vedra FL 32082-4098 Ph: (904) 903-6375 |
| NPI Number | 1053018143 |
|---|---|
| Provider Enumeration Date | 02/09/2023 |
| Last Update Date | 06/01/2023 |
| Certification Date | 06/01/2023 |
| Medicare PECOS PAC ID | 7618335159 |
|---|---|
| Medicare Enrollment ID | O20230615001821 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1053018143 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 106H00000X | Marriage & Family Therapist | (* (Not Available)) | Primary |
| Provider Name | Amy Caroline Macharg |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1194229823 PECOS PAC ID: 0941668495 Enrollment ID: I20230615002012 |
| Provider Name | Rebecca Sotero |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1215633706 PECOS PAC ID: 1557723475 Enrollment ID: I20230809002434 |
| Provider Name | Jessica Holesko |
|---|---|
| Provider Type | Practitioner - Marriage And Family Therapist |
| Provider Identifiers | NPI Number: 1447988472 PECOS PAC ID: 5496106015 Enrollment ID: I20240109000320 |
| Provider Name | William Keith Galer |
|---|---|
| Provider Type | Practitioner - Marriage And Family Therapist |
| Provider Identifiers | NPI Number: 1144562000 PECOS PAC ID: 8426416967 Enrollment ID: I20240121000136 |
| Provider Name | Stephanie Kenton |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1124487947 PECOS PAC ID: 4880047125 Enrollment ID: I20240202000334 |
| Provider Name | Theresa Antima Bauer |
|---|---|
| Provider Type | Practitioner - Marriage And Family Therapist |
| Provider Identifiers | NPI Number: 1912581919 PECOS PAC ID: 5193167732 Enrollment ID: I20240528002160 |
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