MEDICARE: SHERROD ELLIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	22702	TX

General Provider Information

NPI Number	:	1720442817
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHERROD ELLIS

Provider Business Mailing Address
First Line	:	1506 W PIONEER PKWY
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76013-6230
Country	:	US
Telephone Number	:	817-371-2593
Fax Number	:

Provider Business Practice Location Address
First Line	:	1506 W PIONEER PKWY
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76013-6230
Country	:	US
Telephone Number	:	817-371-2593
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2016
Last Update Date	:	04/05/2016

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Directions to “ SHERROD ELLIS ” Practice Location

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