Provider Demographics
NPI:1346052966
Name:ELLIS, GRANT J
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:J
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 1:10 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:WEST TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47885-1202
Mailing Address - Country:US
Mailing Address - Phone:812-201-5763
Mailing Address - Fax:
Practice Address - Street 1:10 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:WEST TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47885-1202
Practice Address - Country:US
Practice Address - Phone:812-201-5763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health