Provider Demographics
NPI:1174925424
Name:ELLIS, DARRELL LEMONT JR (ADMINISTRATOR)
Entity type:Individual
Prefix:MR
First Name:DARRELL
Middle Name:LEMONT
Last Name:ELLIS
Suffix:JR
Gender:M
Credentials:ADMINISTRATOR
Other - Prefix:
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Mailing Address - Street 1:43646 W YUCCA LN
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-2011
Mailing Address - Country:US
Mailing Address - Phone:520-483-4219
Mailing Address - Fax:
Practice Address - Street 1:43646 W YUCCA LN
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85138-2011
Practice Address - Country:US
Practice Address - Phone:520-483-4219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2025-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBHRF20103322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children