Provider Demographics
NPI:1841400132
Name:ELLIS, EDDIE
Entity Type:Individual
Prefix:
First Name:EDDIE
Middle Name:
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 1:420 TIERNEY RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-6324
Mailing Address - Country:US
Mailing Address - Phone:817-534-5480
Mailing Address - Fax:817-534-4748
Practice Address - Street 1:420 TIERNEY RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-6324
Practice Address - Country:US
Practice Address - Phone:817-534-5480
Practice Address - Fax:817-534-4748
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Not Answered103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Not Answered103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities