Provider Demographics
NPI:1356730592
Name:ELLZEY, TERESSA (BSW)
Entity type:Individual
Prefix:MS
First Name:TERESSA
Middle Name:
Last Name:ELLZEY
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 DUNCAN ST
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38663-1801
Mailing Address - Country:US
Mailing Address - Phone:601-470-2262
Mailing Address - Fax:
Practice Address - Street 1:1005 CITY AVE N
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:MS
Practice Address - Zip Code:38663-1414
Practice Address - Country:US
Practice Address - Phone:662-837-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS977OtherEMPLOYEE STAFF NUMBER