Basic Information
| Provider Information | |||||||||
| NPI: | 1922482124 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | STEPHANIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 N WALTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727124576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794641060 | ||||||||
| FaxNumber: | 4792716307 | ||||||||
| Practice Location | |||||||||
| Address1: | 339 HIGHWAY 463 N | ||||||||
| Address2: | |||||||||
| City: | TRUMANN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724723505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704837039 | ||||||||
| FaxNumber: | 8704830590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2015 | ||||||||
| LastUpdateDate: | 07/17/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.