Provider Demographics
NPI:1841949385
Name:ELLIS, WANDA (PHD)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 MAXEY RD # 6
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77013-5017
Mailing Address - Country:US
Mailing Address - Phone:346-509-1013
Mailing Address - Fax:
Practice Address - Street 1:485 MAXEY RD # 6
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77013-5017
Practice Address - Country:US
Practice Address - Phone:346-509-1013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-22
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX373188702Medicaid