Provider Demographics
NPI:1629607015
Name:MCCOMB, ELLIS WELLINGTON
Entity Type:Individual
Prefix:
First Name:ELLIS
Middle Name:WELLINGTON
Last Name:MCCOMB
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 1:4503 HOLMEHURST WAY
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-3455
Mailing Address - Country:US
Mailing Address - Phone:301-219-3429
Mailing Address - Fax:
Practice Address - Street 1:4503 HOLMEHURST WAY
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-3455
Practice Address - Country:US
Practice Address - Phone:301-219-3429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-07
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical