Basic Information
| Provider Information | |||||||||
| NPI: | 1851429294 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | SPENCER | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CASAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 W CRESTWOOD DR | ||||||||
| Address2: | |||||||||
| City: | MONETT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657089577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172353001 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2808 S. PICHER ST. | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173477700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1342 | MO | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.