Provider Demographics
NPI:1083451918
Name:ELLIS, TINA MARIE (EARLY INTERVENTION)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:EARLY INTERVENTION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 PLANTATION DR
Mailing Address - Street 2:
Mailing Address - City:MINERAL WELLS
Mailing Address - State:WV
Mailing Address - Zip Code:26150-9638
Mailing Address - Country:US
Mailing Address - Phone:304-483-3077
Mailing Address - Fax:
Practice Address - Street 1:225 PLANTATION DR
Practice Address - Street 2:
Practice Address - City:MINERAL WELLS
Practice Address - State:WV
Practice Address - Zip Code:26150-9638
Practice Address - Country:US
Practice Address - Phone:304-483-3077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency