Provider Demographics
NPI:1912289174
Name:ELLIS, MONA SWAFFORD (LCDC, CHW)
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:SWAFFORD
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LCDC, CHW
Other - Prefix:
Other - First Name:MONA
Other - Middle Name:FAYE
Other - Last Name:SWAFFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:507 N SAM HOUSTON PKWY E
Mailing Address - Street 2:SUITE 270
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77060-4021
Mailing Address - Country:US
Mailing Address - Phone:713-266-2090
Mailing Address - Fax:800-434-4305
Practice Address - Street 1:507 N SAM HOUSTON PKWY E
Practice Address - Street 2:SUITE 270
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77060-4021
Practice Address - Country:US
Practice Address - Phone:713-266-2090
Practice Address - Fax:800-434-4305
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-14
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172A00000X, 251S00000X, 101YM0800X, 171M00000X
TX06046953347C00000X
TX1944172V00000X, 174H00000X
TX13157101Y00000X, 101YA0400X
TX101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No172A00000XOther Service ProvidersDriverGroup - Single Specialty
No347C00000XTransportation ServicesPrivate VehicleGroup - Single Specialty
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX12165OtherTEXAS DEPARTMENT OF STATE HEALTH SERVICES/COUNELOR INTERN
TX01944OtherTEXAS DEPARTMENT OF STATE HEALTH SERVICES/COMMUNITY HEALTHCARE WORKER/PROMOTOR