Provider Demographics
NPI:1437800695
Name:ELLIS, THOMAS (MS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:ELLIS
Other - Middle Name:
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:1540 INTERNATIONAL PARKWAY
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5096
Mailing Address - Country:US
Mailing Address - Phone:904-800-8919
Mailing Address - Fax:
Practice Address - Street 1:1540 INTERNATIONAL PARKWAY
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-5096
Practice Address - Country:US
Practice Address - Phone:904-800-8919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health