Provider Demographics
NPI:1013111459
Name:ELLIS, EARL EDWARD (MED, LPA)
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:EDWARD
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MED, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 RINEYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-8927
Mailing Address - Country:US
Mailing Address - Phone:270-234-9236
Mailing Address - Fax:270-234-8367
Practice Address - Street 1:890 RINEYVILLE RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-8927
Practice Address - Country:US
Practice Address - Phone:270-234-9236
Practice Address - Fax:270-234-8367
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0952103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist