Doctor Name: | MRS. ETHEL BOGAN ELLIS |
NPI Number: | 1780883553 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | |
License Number: | |
Business Practice Address: | 1110 Kingston Drive Wharton, TX - 774885708 |
Business Phone Number: | 9795323720 |
Business Fax Number: | 9795323720 |
Mailing Address: | 1110 Kingston Dr, WHARTON |
State: | TX |
Postal Code: | 774885708 |
Phone Number: | 9795323720 |
Fax Number: | 9795323720 |
NPI Enumeration Date: | 07/12/2007 |
NPI Last Update Date: | 07/12/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 320900000X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Residential Treatment Facilities |
Taxonomy Classification: | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
Taxonomy Specialization: | |
Taxonomy Definition: | A home-like residential facility providing habilitation, support and monitoring services to individuals diagnosed with mental retardation and/or developmental disabilities. |