MEDICARE: MONA SWAFFORD ELLIS LCDC, CHW

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	172A00000X	Driver
2	347C00000X	Private Vehicle	06046953	TX
3	172V00000X	Community Health Worker	1944	TX
4	174H00000X	Health Educator	1944	TX
5	251S00000X	Community/Behavioral Health Agency
6	101Y00000X	Counselor	13157	TX
7	101YA0400X	Addiction (Substance Use Disorder) Counselor	13157	TX
8	101YM0800X	Mental Health Counselor
9	101YP1600X	Pastoral Counselor		TX
10	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1912289174
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MONA SWAFFORD ELLIS LCDC, CHW

Provider Business Mailing Address
First Line	:	507 N SAM HOUSTON PKWY E
Second Line	:	SUITE 270
City	:	HOUSTON
State	:	TX
Zip	:	77060-4021
Country	:	US
Telephone Number	:	713-266-2090
Fax Number	:	800-434-4305

Provider Business Practice Location Address
First Line	:	507 N SAM HOUSTON PKWY E
Second Line	:	SUITE 270
City	:	HOUSTON
State	:	TX
Zip	:	77060-4021
Country	:	US
Telephone Number	:	713-266-2090
Fax Number	:	800-434-4305

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

Provider Enumeration Date	:	09/14/2011
Last Update Date	:	10/01/2015

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