Provider Demographics
NPI:1649747411
Name:ELLIS, SUMMER ANGEL
Entity Type:Individual
Prefix:
First Name:SUMMER
Middle Name:ANGEL
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 WOODLAND ST NE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-5348
Mailing Address - Country:US
Mailing Address - Phone:330-469-6777
Mailing Address - Fax:330-469-6779
Practice Address - Street 1:1705 WOODLAND ST NE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-5348
Practice Address - Country:US
Practice Address - Phone:330-469-6777
Practice Address - Fax:330-469-6779
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)