Provider Demographics
NPI:1336576966
Name:ELLEDGE, MARY ANN
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ANN
Last Name:ELLEDGE
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:PO BOX 1494
Mailing Address - Street 2:
Mailing Address - City:LANGSTON
Mailing Address - State:OK
Mailing Address - Zip Code:73050
Mailing Address - Country:US
Mailing Address - Phone:405-466-9178
Mailing Address - Fax:
Practice Address - Street 1:513 S.W. BRUCE ST.
Practice Address - Street 2:
Practice Address - City:LANGSTON
Practice Address - State:OK
Practice Address - Zip Code:73050
Practice Address - Country:US
Practice Address - Phone:405-412-8020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-27
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst