Provider Demographics
NPI:1285720623
Name:ELLIS, HEATHER (MA)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:COBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5707 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610
Mailing Address - Country:US
Mailing Address - Phone:813-673-4622
Mailing Address - Fax:813-356-1691
Practice Address - Street 1:5707 N 22ND ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610
Practice Address - Country:US
Practice Address - Phone:813-673-4622
Practice Address - Fax:813-356-1691
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker