Provider Demographics
NPI:1639862139
Name:ELLIS, HOLLY
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5625 WILDFLOWER CT
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-8882
Mailing Address - Country:US
Mailing Address - Phone:870-340-7808
Mailing Address - Fax:
Practice Address - Street 1:900 SOUTHWEST DR STE D
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7077
Practice Address - Country:US
Practice Address - Phone:870-842-3274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2025-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR106S00000X
373H00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist