Provider Demographics
NPI:1124526322
Name:ELLIS, KHALIHAH (CSW)
Entity type:Individual
Prefix:MS
First Name:KHALIHAH
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 FAIRWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-3609
Mailing Address - Country:US
Mailing Address - Phone:662-230-2144
Mailing Address - Fax:
Practice Address - Street 1:980 FAIRWOOD DR
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-3609
Practice Address - Country:US
Practice Address - Phone:662-230-2144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-23
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1108804Medicaid