Provider Demographics
NPI:1114428091
Name:ELLIS, KEIAH (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEIAH
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7832 OAK CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-8811
Mailing Address - Country:US
Mailing Address - Phone:318-344-3770
Mailing Address - Fax:
Practice Address - Street 1:7832 OAK CREEK TRL
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-8811
Practice Address - Country:US
Practice Address - Phone:318-344-3770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral