Provider Demographics
NPI:1376906172
Name:ELLIS, STEPHANIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4107 HARBOR POINT DR
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-1836
Mailing Address - Country:US
Mailing Address - Phone:713-302-6494
Mailing Address - Fax:
Practice Address - Street 1:11999 KATY FWY STE 490
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77079-1608
Practice Address - Country:US
Practice Address - Phone:713-302-6494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34722103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling