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NPI Code Detail

MEDICARE: EDDIE ELLIS

MEDICARE: EDDIE 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
1101YM0800XMental Health Counselor
2103TA0700XAdult Development & Aging Psychologist
3103TH0100XHealth Service Psychologist
4103TM1800XIntellectual & Developmental Disabilities Psychologist

General Provider Information

NPI Number : 1841400132
Entity Type Code : Individual
Provider Name (Legal Business Name) : EDDIE ELLIS
Provider Business Mailing Address
First Line : 420 TIERNEY RD
Second Line :
City : FORT WORTH
State : TX
Zip : 76112-6324
Country : US
Telephone Number : 817-534-5480
Fax Number : 817-534-4748
Provider Business Practice Location Address
First Line : 420 TIERNEY RD
Second Line :
City : FORT WORTH
State : TX
Zip : 76112-6324
Country : US
Telephone Number : 817-534-5480
Fax Number : 817-534-4748
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/23/2007
Last Update Date : 09/11/2025

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Directions to “ EDDIE ELLIS ” Practice Location

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