Provider Demographics
NPI:1487892485
Name:ELLIS, LISA A
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:A
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 S FAIR ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-3122
Mailing Address - Country:US
Mailing Address - Phone:217-377-9348
Mailing Address - Fax:
Practice Address - Street 1:309 S FAIR ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-3122
Practice Address - Country:US
Practice Address - Phone:217-377-9348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-28
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency