Provider Demographics
NPI:1821611518
Name:ELLIS, JAVIOUS (MSW)
Entity Type:Individual
Prefix:
First Name:JAVIOUS
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 ENOLA DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-8122
Mailing Address - Country:US
Mailing Address - Phone:704-692-5062
Mailing Address - Fax:
Practice Address - Street 1:809 N LAFAYETTE ST STE A
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3886
Practice Address - Country:US
Practice Address - Phone:704-692-5062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-28
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
NCP0149221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional