1629008313 NPI number — GEERTINA H ELLIS HSP-PA, LPA

Table of content: GEERTINA H ELLIS HSP-PA, LPA (NPI 1629008313)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629008313 NPI number — GEERTINA H ELLIS HSP-PA, LPA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIS
Provider First Name:
GEERTINA
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
HSP-PA, LPA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ELLIS
Provider Other First Name:
GEERTINA
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
ED.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1629008313
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5242 SUNDOWN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28303-3287
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-578-3451
Provider Business Mailing Address Fax Number:
910-487-0703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5242 SUNDOWN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28303-3287
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-670-9689
Provider Business Practice Location Address Fax Number:
910-487-0703
Provider Enumeration Date:
07/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  2167 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103T00000X , with the licence number: NC2167 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 84-1999514 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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