Provider Demographics
NPI:1720442817
Name:ELLIS, SHERROD
Entity Type:Individual
Prefix:
First Name:SHERROD
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 W PIONEER PKWY
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76013-6230
Mailing Address - Country:US
Mailing Address - Phone:817-371-2593
Mailing Address - Fax:
Practice Address - Street 1:1506 W PIONEER PKWY
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76013-6230
Practice Address - Country:US
Practice Address - Phone:817-371-2593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22702101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)