Provider Demographics
NPI:1740481480
Name:ELLIS, QUINTON (LPC)
Entity type:Individual
Prefix:
First Name:QUINTON
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 S BRYANT AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-5826
Mailing Address - Country:US
Mailing Address - Phone:405-760-4148
Mailing Address - Fax:
Practice Address - Street 1:1008 S BRYANT AVE STE 140
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-5826
Practice Address - Country:US
Practice Address - Phone:405-760-4148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK04104101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health