Provider Demographics
NPI:1275239089
Name:ELLIS, DEKARA
Entity Type:Individual
Prefix:
First Name:DEKARA
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 1:2101 TOWER DR STE B
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5045
Mailing Address - Country:US
Mailing Address - Phone:318-323-1300
Mailing Address - Fax:
Practice Address - Street 1:2101 TOWER DR STE B
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5045
Practice Address - Country:US
Practice Address - Phone:318-323-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator