Provider Demographics
NPI:1609400639
Name:ELLINGSON, TERRA L (CMHT)
Entity Type:Individual
Prefix:
First Name:TERRA
Middle Name:L
Last Name:ELLINGSON
Suffix:
Gender:F
Credentials:CMHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2291
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58802-2291
Mailing Address - Country:US
Mailing Address - Phone:701-577-0270
Mailing Address - Fax:701-577-0271
Practice Address - Street 1:719 EAST 11TH STREET
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801
Practice Address - Country:US
Practice Address - Phone:701-572-6181
Practice Address - Fax:701-572-8783
Is Sole Proprietor?:No
Enumeration Date:2020-02-28
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1516OtherNORTH DAKOTA HUMAN SERVICES