Provider Demographics
NPI:1124499405
Name:ELLIS, LARRY D
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:D
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 1:20 DEER TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:SELMER
Mailing Address - State:TN
Mailing Address - Zip Code:38375-6695
Mailing Address - Country:US
Mailing Address - Phone:931-209-0619
Mailing Address - Fax:
Practice Address - Street 1:2664 S HARPER RD
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-6723
Practice Address - Country:US
Practice Address - Phone:662-287-4055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health