Provider Demographics
NPI:1568992741
Name:ELLIS, DAWAUNE LATIEFTH
Entity Type:Individual
Prefix:
First Name:DAWAUNE
Middle Name:LATIEFTH
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 S TROY ST STE 209
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-1946
Mailing Address - Country:US
Mailing Address - Phone:303-671-2480
Mailing Address - Fax:303-671-2480
Practice Address - Street 1:2323 S TROY ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-1946
Practice Address - Country:US
Practice Address - Phone:720-882-2421
Practice Address - Fax:720-882-2421
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO920653694Medicaid