Provider Demographics
NPI:1255524062
Name:ELLIS, DAVID WESLEY (MA, LPC, CAC-II)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:WESLEY
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MA, LPC, CAC-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2801 YOUNGFIELD ST
Mailing Address - Street 2:STE 300
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401-2263
Mailing Address - Country:US
Mailing Address - Phone:303-205-8468
Mailing Address - Fax:303-232-0384
Practice Address - Street 1:2801 YOUNGFIELD ST
Practice Address - Street 2:STE 300
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80401-2263
Practice Address - Country:US
Practice Address - Phone:303-205-8468
Practice Address - Fax:303-232-0384
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6513101YA0400X
CO3230101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO93174225Medicaid