Provider Demographics
NPI:1922453182
Name:ELLOW, COREY
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:ELLOW
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 1:908 W JUDGE PEREZ DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHALMETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70043-4773
Mailing Address - Country:US
Mailing Address - Phone:504-324-5298
Mailing Address - Fax:
Practice Address - Street 1:908 W JUDGE PEREZ DR
Practice Address - Street 2:SUITE C
Practice Address - City:CHALMETTE
Practice Address - State:LA
Practice Address - Zip Code:70043-4773
Practice Address - Country:US
Practice Address - Phone:504-324-5298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101Y00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1750754727Medicaid
LA1750754727OtherMHR