Provider Demographics
NPI:1508875022
Name:ELLARD, BRET L (MED)
Entity Type:Individual
Prefix:MR
First Name:BRET
Middle Name:L
Last Name:ELLARD
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-6801
Mailing Address - Country:US
Mailing Address - Phone:405-275-2222
Mailing Address - Fax:405-275-7740
Practice Address - Street 1:1 W 10TH ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-6801
Practice Address - Country:US
Practice Address - Phone:405-275-2222
Practice Address - Fax:405-275-7740
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLPC 1300101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional