Provider Demographics
NPI:1184020968
Name:ELLIS, CHARLES JR
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:ELLIS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5130 S PECOS RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-1201
Mailing Address - Country:US
Mailing Address - Phone:702-560-5973
Mailing Address - Fax:
Practice Address - Street 1:5130 S PECOS RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-1201
Practice Address - Country:US
Practice Address - Phone:702-560-5973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health