Provider Demographics
NPI:1518659234
Name:ELLIS, MARTIN JR (CDCA)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:
Last Name:ELLIS
Suffix:JR
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 S REYNOLDS RD STE C
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-6958
Mailing Address - Country:US
Mailing Address - Phone:419-725-6631
Mailing Address - Fax:
Practice Address - Street 1:115 S REYNOLDS RD STE C
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-6958
Practice Address - Country:US
Practice Address - Phone:419-725-6631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.182995101YA0400X
OHCDCA.187515101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)