Provider Demographics
NPI:1164777124
Name:ELLIS, STEPHANI
Entity Type:Individual
Prefix:
First Name:STEPHANI
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 1:907 BANCROFT PL
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-5040
Mailing Address - Country:US
Mailing Address - Phone:630-308-2389
Mailing Address - Fax:815-544-5581
Practice Address - Street 1:907 BANCROFT PL
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-5040
Practice Address - Country:US
Practice Address - Phone:630-308-2389
Practice Address - Fax:815-544-5581
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL471661252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency