Provider Demographics
NPI:1538489752
Name:ELLIS, EBONI (MHPP)
Entity Type:Individual
Prefix:
First Name:EBONI
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 CANTRELL RD
Mailing Address - Street 2:APARTMENT Q101
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72207-4160
Mailing Address - Country:US
Mailing Address - Phone:501-256-3403
Mailing Address - Fax:
Practice Address - Street 1:4701 FAIRWAY AVE
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-8066
Practice Address - Country:US
Practice Address - Phone:501-771-8261
Practice Address - Fax:501-771-8263
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator