Provider Demographics
NPI:1366105207
Name:ELLIS, AUDRENE (PHD)
Entity type:Individual
Prefix:
First Name:AUDRENE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:AUDREN
Other - Middle Name:JANELLE
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:101 N WOODROW ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-4341
Mailing Address - Country:US
Mailing Address - Phone:501-265-0046
Mailing Address - Fax:501-265-0057
Practice Address - Street 1:101 N WOODROW ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-4341
Practice Address - Country:US
Practice Address - Phone:501-265-0046
Practice Address - Fax:501-663-2234
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP2211007101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor