Provider Demographics
NPI:1225536113
Name:STANDBERRY, ELLEN FAYE
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:FAYE
Last Name:STANDBERRY
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:PO BOX 2413
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75030-2413
Mailing Address - Country:US
Mailing Address - Phone:214-600-2513
Mailing Address - Fax:
Practice Address - Street 1:301 SANTOS DR
Practice Address - Street 2:
Practice Address - City:ROYSE CITY
Practice Address - State:TX
Practice Address - Zip Code:75189-5111
Practice Address - Country:US
Practice Address - Phone:214-600-2513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities