Provider Demographics
NPI:1902188949
Name:ELLIS, WACONDA
Entity Type:Individual
Prefix:
First Name:WACONDA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5304 DAYWOOD ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-7917
Mailing Address - Country:US
Mailing Address - Phone:702-649-5995
Mailing Address - Fax:702-399-9801
Practice Address - Street 1:5304 DAYWOOD ST
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-7917
Practice Address - Country:US
Practice Address - Phone:702-649-5995
Practice Address - Fax:702-399-9801
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor