Provider Demographics
NPI:1871029314
Name:CHARLES, ELLIS TIMOTHY
Entity Type:Individual
Prefix:
First Name:ELLIS
Middle Name:TIMOTHY
Last Name:CHARLES
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 1:511 GLADSTONE ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-4830
Mailing Address - Country:US
Mailing Address - Phone:307-752-9082
Mailing Address - Fax:
Practice Address - Street 1:511 GLADSTONE ST
Practice Address - Street 2:511 GLADSTONE STREET
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-4830
Practice Address - Country:US
Practice Address - Phone:307-752-9082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services