Provider Demographics
NPI:1124392592
Name:ELLIS, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 N WALTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-4576
Mailing Address - Country:US
Mailing Address - Phone:479-271-6302
Mailing Address - Fax:479-271-6307
Practice Address - Street 1:229 A ST
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-3653
Practice Address - Country:US
Practice Address - Phone:870-367-2141
Practice Address - Fax:870-234-9481
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor