Provider Demographics
NPI:1932347242
Name:TELLIS, PHYLLIS A
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:A
Last Name:TELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2560 W BROOKS AVE # F
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-3832
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2560 W BROOKS AVE # F
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-3832
Practice Address - Country:US
Practice Address - Phone:702-780-4932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-23
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 106S00000X, 171M00000X, 174H00000X, 103K00000X
NV246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No174H00000XOther Service ProvidersHealth Educator
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst