Provider Demographics
NPI:1174909451
Name:ELLZEY, ANTONIO CLARENCE SR (NCC, LCPC)
Entity type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:CLARENCE
Last Name:ELLZEY
Suffix:SR
Gender:M
Credentials:NCC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9119S EXCHANGE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-4225
Mailing Address - Country:US
Mailing Address - Phone:773-768-5000
Mailing Address - Fax:
Practice Address - Street 1:9435 BORMET DR STE 5
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-7401
Practice Address - Country:US
Practice Address - Phone:708-995-7226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-10
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILEIN-27-4113346101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1205137346OtherGROUP NPI