Provider Demographics
NPI:1609221290
Name:KING, ELLIS
Entity Type:Individual
Prefix:
First Name:ELLIS
Middle Name:
Last Name:KING
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 1:100 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-5084
Mailing Address - Country:US
Mailing Address - Phone:918-420-5343
Mailing Address - Fax:918-420-5904
Practice Address - Street 1:100 N 5TH ST
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5084
Practice Address - Country:US
Practice Address - Phone:918-420-5343
Practice Address - Fax:918-420-5904
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-02
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor