Provider Demographics
NPI:1982974622
Name:ELLIS, TRACY KENT
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:KENT
Last Name:ELLIS
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 1:208 N WITTE ST
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-3926
Mailing Address - Country:US
Mailing Address - Phone:918-809-0112
Mailing Address - Fax:
Practice Address - Street 1:900 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2617
Practice Address - Country:US
Practice Address - Phone:918-809-0112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst