Provider Demographics
NPI:1821677576
Name:ELLIS, GEORGE THEMEO
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:THEMEO
Last Name:ELLIS
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 1:150 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-7739
Mailing Address - Country:US
Mailing Address - Phone:612-816-7274
Mailing Address - Fax:
Practice Address - Street 1:150 SCENIC DR
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-7739
Practice Address - Country:US
Practice Address - Phone:612-816-7274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1353103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical