Provider Demographics
NPI:1992038988
Name:ELLZEY, NAN (LCDC)
Entity Type:Individual
Prefix:
First Name:NAN
Middle Name:
Last Name:ELLZEY
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 THOUSAND OAKS DR
Mailing Address - Street 2:SUITE 1603
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-2399
Mailing Address - Country:US
Mailing Address - Phone:210-325-3242
Mailing Address - Fax:
Practice Address - Street 1:1550 THOUSAND OAKS DR
Practice Address - Street 2:SUITE 1603
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-2399
Practice Address - Country:US
Practice Address - Phone:210-325-3242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-09
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7653101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)