Provider Demographics
NPI:1417256900
Name:ELLIS THOMAS, CHARVELLE L
Entity Type:Individual
Prefix:MRS
First Name:CHARVELLE
Middle Name:L
Last Name:ELLIS THOMAS
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 1:880 E LEHIGH DR
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32738-7733
Mailing Address - Country:US
Mailing Address - Phone:386-259-4985
Mailing Address - Fax:386-259-4987
Practice Address - Street 1:880 E LEHIGH DR
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32738-7733
Practice Address - Country:US
Practice Address - Phone:386-259-4985
Practice Address - Fax:386-259-4987
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-23
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator