Provider Demographics
NPI:1417571183
Name:ELLIS, ALECIA M
Entity Type:Individual
Prefix:
First Name:ALECIA
Middle Name:M
Last Name:ELLIS
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 1:805 CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:PLEASANTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08232-4204
Mailing Address - Country:US
Mailing Address - Phone:215-275-9984
Mailing Address - Fax:
Practice Address - Street 1:805 CEDAR LN
Practice Address - Street 2:
Practice Address - City:PLEASANTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08232-4204
Practice Address - Country:US
Practice Address - Phone:215-275-9984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-29
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities