Provider Demographics
NPI:1215175591
Name:ELLIS, LAWRENCE EUGENE (LADC)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:EUGENE
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 NE 43RD ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73111-5853
Mailing Address - Country:US
Mailing Address - Phone:405-824-5066
Mailing Address - Fax:
Practice Address - Street 1:2401 N.W. 39TH I 44 SERVICE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-8739
Practice Address - Country:US
Practice Address - Phone:405-557-1655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-26
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK366101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK10OtherINSURE OKLAHOMA
OK1OtherINSURE OKLAHOMA