Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 32287 | TX |
NPI | 1417443573 |
---|---|
Provider Name | Sydney Ellis |
First Address | Plano, TX 75074-5306 |
Second Address | Frisco, TX 75033 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/07/2018 |
Last Update Date | 18/07/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
32287 | LICENSE NUMBER (01) | TX |