Provider Demographics
NPI:1457477903
Name:ELLIS, SUSAN BETHEA (MA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:BETHEA
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:BETHEA
Other - Last Name:JAMES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2810 LEISURE LN
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-4734
Mailing Address - Country:US
Mailing Address - Phone:972-416-5511
Mailing Address - Fax:972-416-9850
Practice Address - Street 1:2810 LEISURE LN
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-4734
Practice Address - Country:US
Practice Address - Phone:972-416-5511
Practice Address - Fax:972-416-9850
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4253106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist