Provider Demographics
NPI:1114919636
Name:ELLIS, OREN MICHAEL (LPE)
Entity Type:Individual
Prefix:
First Name:OREN
Middle Name:MICHAEL
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LPE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6350 W A J HWY
Mailing Address - Street 2:DEPARTMENT 100
Mailing Address - City:TALBOTT
Mailing Address - State:TN
Mailing Address - Zip Code:37877-8605
Mailing Address - Country:US
Mailing Address - Phone:800-355-3565
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:6350 W ANDREW JOHNSON HWY
Practice Address - Street 2:
Practice Address - City:TALBOTT
Practice Address - State:TN
Practice Address - Zip Code:37877-8605
Practice Address - Country:US
Practice Address - Phone:423-587-7337
Practice Address - Fax:423-586-0614
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPE1721103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical