Provider Demographics
NPI:1275840803
Name:ELLIS, LINDA PETTIS (PHD, NCC, LPC-S)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:PETTIS
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PHD, NCC, LPC-S
Other - Prefix:DR
Other - First Name:LINDA
Other - Middle Name:M
Other - Last Name:PETTIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3223 HUMMINGBIRD LN
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77396-4137
Mailing Address - Country:US
Mailing Address - Phone:346-404-8816
Mailing Address - Fax:
Practice Address - Street 1:3223 HUMMINGBIRD LN
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77396-4137
Practice Address - Country:US
Practice Address - Phone:346-404-8816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-02
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10523101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX218552202Medicaid