Provider Demographics
NPI:1598272437
Name:ELLIS, KEVIN DAYTON (LICDC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:DAYTON
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2009 E PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-5337
Mailing Address - Country:US
Mailing Address - Phone:440-812-2552
Mailing Address - Fax:
Practice Address - Street 1:2801 C CT
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-4577
Practice Address - Country:US
Practice Address - Phone:440-998-0722
Practice Address - Fax:440-992-1699
Is Sole Proprietor?:No
Enumeration Date:2017-12-31
Last Update Date:2017-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH161600101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH161600OtherOHIO CHEMICAL DEPENDENCY PROFESSIONALS BOARD