Provider Demographics
NPI:1124064233
Name:ELLIS, MAVONNA MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:MAVONNA
Middle Name:MARIE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 S AUGUST ST
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-1837
Mailing Address - Country:US
Mailing Address - Phone:405-564-0656
Mailing Address - Fax:
Practice Address - Street 1:1616 S AUGUST ST
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-1837
Practice Address - Country:US
Practice Address - Phone:405-564-0656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3974101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health