Provider Demographics
NPI:1356400329
Name:SUMRALL, ELLEN PATRICE (BA PSYCHOLOGY)
Entity type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:PATRICE
Last Name:SUMRALL
Suffix:
Gender:F
Credentials:BA PSYCHOLOGY
Other - Prefix:MS
Other - First Name:ELLEN
Other - Middle Name:PATRICE
Other - Last Name:SUMRALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BA PSYCHOLOGY
Mailing Address - Street 1:3855 LLEWELYN DR
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608
Mailing Address - Country:US
Mailing Address - Phone:251-342-7337
Mailing Address - Fax:
Practice Address - Street 1:57 INDUSTRIAL PK RD
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452
Practice Address - Country:US
Practice Address - Phone:228-947-4274
Practice Address - Fax:228-947-4275
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018214Medicaid