Provider Demographics
NPI:1225610470
Name:ELLIS, ERIC ALEXANDER (CDCA, PRS)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:ALEXANDER
Last Name:ELLIS
Suffix:
Gender:M
Credentials:CDCA, PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-1610
Mailing Address - Country:US
Mailing Address - Phone:740-532-3767
Mailing Address - Fax:740-532-3385
Practice Address - Street 1:214 S 4TH ST
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-1610
Practice Address - Country:US
Practice Address - Phone:740-532-3767
Practice Address - Fax:740-532-3385
Is Sole Proprietor?:No
Enumeration Date:2021-04-27
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0002782175T00000X
OHCDCA.178795101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist