Provider Demographics
NPI:1417443573
Name:ELLIS, SYDNEY (LCDC)
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 K AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-5306
Mailing Address - Country:US
Mailing Address - Phone:972-423-8727
Mailing Address - Fax:972-423-8918
Practice Address - Street 1:4280 MAIN ST STE 300
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033
Practice Address - Country:US
Practice Address - Phone:972-905-6574
Practice Address - Fax:972-423-8918
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32287103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX32287OtherLICENSE NUMBER