Provider Demographics
NPI:1881172393
Name:ELLIS-ELGART, WILLIAM TRENT
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:TRENT
Last Name:ELLIS-ELGART
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 1:4890 NUNU RD
Mailing Address - Street 2:
Mailing Address - City:KAPAA
Mailing Address - State:HI
Mailing Address - Zip Code:96746-1938
Mailing Address - Country:US
Mailing Address - Phone:808-639-6486
Mailing Address - Fax:
Practice Address - Street 1:4890 NUNU RD
Practice Address - Street 2:
Practice Address - City:KAPAA
Practice Address - State:HI
Practice Address - Zip Code:96746-1938
Practice Address - Country:US
Practice Address - Phone:808-639-6486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-06
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIH01060740106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty