Provider Demographics
NPI:1902188212
Name:ELLZEY, TERRI (BS)
Entity Type:Individual
Prefix:MRS
First Name:TERRI
Middle Name:
Last Name:ELLZEY
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2779 N 55TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-1558
Mailing Address - Country:US
Mailing Address - Phone:414-344-3406
Mailing Address - Fax:414-344-0107
Practice Address - Street 1:2779 N 55TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1558
Practice Address - Country:US
Practice Address - Phone:414-344-3406
Practice Address - Fax:414-344-0107
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15614131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)