Basic Information
Provider Information | |||||||||
NPI: | 1215574207 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ELLIS | ||||||||
FirstName: | LAKENDRIA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ELLIS | ||||||||
OtherFirstName: | LAKENDRIA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LPC | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 2902 LONGHORN CIR | ||||||||
Address2: |   | ||||||||
City: | MANVEL | ||||||||
State: | TX | ||||||||
PostalCode: | 775783268 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2816929822 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 9401 SOUTHWEST FWY | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770741407 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7139707000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/09/2019 | ||||||||
LastUpdateDate: | 12/09/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/09/2019 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 78992 | TX | N |   | Behavioral Health & Social Service Providers | Counselor |   | 101YM0800X | 78992 | TX | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 78992 | TX | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.