1306257639 NPI number — TERRI ELLIS PSR TECH

Table of content: TERRI ELLIS PSR TECH (NPI 1306257639)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306257639 NPI number — TERRI ELLIS PSR TECH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIS
Provider First Name:
TERRI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSR TECH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306257639
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
935 HIGHWAY V V
Provider Second Line Business Mailing Address:
FAMILY COUNSELING CENTER, INC.
Provider Business Mailing Address City Name:
KENNETT
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63857
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-888-0642
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
925 HIGHWAY V V
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNETT
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63857-0071
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-888-0642
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/08/2014

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: 172V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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