Provider Demographics
NPI:1396125043
Name:TEMPLE ELLIS
Entity type:Organization
Organization Name:TEMPLE ELLIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED INDEPENDENT SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:TEMPLE
Authorized Official - Middle Name:T
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-S
Authorized Official - Phone:614-354-0831
Mailing Address - Street 1:3050 PENTON ST
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-8217
Mailing Address - Country:US
Mailing Address - Phone:614-354-0831
Mailing Address - Fax:
Practice Address - Street 1:3050 PENTON ST
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-8217
Practice Address - Country:US
Practice Address - Phone:614-354-0831
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-08
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1100139-SUPV251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health