Provider Demographics
NPI:1689911794
Name:ELLIS, SUSAN KAY
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KAY
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 1:1222 10TH ST
Mailing Address - Street 2:301
Mailing Address - City:WOODWARD
Mailing Address - State:OK
Mailing Address - Zip Code:73801-3156
Mailing Address - Country:US
Mailing Address - Phone:580-256-8615
Mailing Address - Fax:580-256-8609
Practice Address - Street 1:1222 10TH ST
Practice Address - Street 2:301
Practice Address - City:WOODWARD
Practice Address - State:OK
Practice Address - Zip Code:73801-3156
Practice Address - Country:US
Practice Address - Phone:580-256-8615
Practice Address - Fax:580-256-8609
Is Sole Proprietor?:No
Enumeration Date:2013-01-09
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5368101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional