Provider Demographics
NPI:1174925424
Name:ELLIS, DARRELL LEMONT JR (ADMINISTRATOR)
Entity type:Individual
Prefix:MR
First Name:DARRELL
Middle Name:LEMONT
Last Name:ELLIS
Suffix:JR
Gender:M
Credentials:ADMINISTRATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 N. LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122
Mailing Address - Country:US
Mailing Address - Phone:480-560-8924
Mailing Address - Fax:
Practice Address - Street 1:304 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-4634
Practice Address - Country:US
Practice Address - Phone:480-560-8924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-4483320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness