Provider Demographics
NPI:1033842422
Name:ELLISON, GENELL (MBA, MAHS)
Entity Type:Individual
Prefix:
First Name:GENELL
Middle Name:
Last Name:ELLISON
Suffix:
Gender:F
Credentials:MBA, MAHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4363 LISBON ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80249-6943
Mailing Address - Country:US
Mailing Address - Phone:720-329-6034
Mailing Address - Fax:
Practice Address - Street 1:10400 E ALAMEDA AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80247-5104
Practice Address - Country:US
Practice Address - Phone:303-360-1343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator