Provider Demographics
NPI:1164582821
Name:ELLISVILLE STATE SCHOOL
Entity Type:Organization
Organization Name:ELLISVILLE STATE SCHOOL
Other - Org Name:EPSDT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF FACILITY
Authorized Official - Prefix:DR
Authorized Official - First Name:SUZIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LASSITER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-477-9384
Mailing Address - Street 1:1101 HIGHWAY 11 S
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39437-4443
Mailing Address - Country:US
Mailing Address - Phone:601-477-9384
Mailing Address - Fax:601-477-5700
Practice Address - Street 1:1101 HIGHWAY 11 S
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39437-4443
Practice Address - Country:US
Practice Address - Phone:601-477-9384
Practice Address - Fax:601-477-5700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSESS-BMR374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374700000XNursing Service Related ProvidersTechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015542Medicaid