Provider Demographics
NPI:1295042869
Name:ELLIS, MARY ANN (EDS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20114 E PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:DUNNELLON
Mailing Address - State:FL
Mailing Address - Zip Code:34432-6033
Mailing Address - Country:US
Mailing Address - Phone:352-465-2444
Mailing Address - Fax:352-465-7854
Practice Address - Street 1:20114 E PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:DUNNELLON
Practice Address - State:FL
Practice Address - Zip Code:34432-6033
Practice Address - Country:US
Practice Address - Phone:352-465-2444
Practice Address - Fax:352-465-7854
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-02
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS 830103TS0200X
FLSS830101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1639229362Medicaid