Provider Demographics
NPI:1164763777
Name:ELLIS, CHARLES WAYNE (CACI, MAC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:WAYNE
Last Name:ELLIS
Suffix:
Gender:M
Credentials:CACI, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12304 JACQUELYN CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-9017
Mailing Address - Country:US
Mailing Address - Phone:704-575-6165
Mailing Address - Fax:
Practice Address - Street 1:199 S HERLONG AVE
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1186
Practice Address - Country:US
Practice Address - Phone:803-324-1800
Practice Address - Fax:803-328-3831
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1211149101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)