Provider Demographics
NPI:1184910648
Name:ELLIS, LINDA J
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:J
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 1:108 CORONA DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73149-1808
Mailing Address - Country:US
Mailing Address - Phone:405-388-3299
Mailing Address - Fax:405-635-9245
Practice Address - Street 1:108 CORONA DRIVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73149
Practice Address - Country:US
Practice Address - Phone:405-388-9245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health