Provider Demographics
NPI:1982566774
Name:ELLIS, MARQUISHA KENTRELL
Entity type:Individual
Prefix:
First Name:MARQUISHA
Middle Name:KENTRELL
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 1:701 FESSEY PARK RD APT 104
Mailing Address - Street 2:
Mailing Address - City:BERRY HILL
Mailing Address - State:TN
Mailing Address - Zip Code:37204-3262
Mailing Address - Country:US
Mailing Address - Phone:901-601-8908
Mailing Address - Fax:
Practice Address - Street 1:701 FESSEY PARK RD APT 104
Practice Address - Street 2:
Practice Address - City:BERRY HILL
Practice Address - State:TN
Practice Address - Zip Code:37204-3262
Practice Address - Country:US
Practice Address - Phone:901-601-8908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-12-01
Last Update Date:2025-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN144481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical