Healthcare Provider Details

I. General information

NPI: 1215852207
Provider Name (Legal Business Name): WILLIAM L ELLIS SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2412 16TH AVE APT A
COLUMBUS GA
31901-1311
US

IV. Provider business mailing address

2412 16TH AVE APT A
COLUMBUS GA
31901-1311
US

V. Phone/Fax

Practice location:
  • Phone: 706-801-6505
  • Fax: 706-801-6505
Mailing address:
  • Phone: 706-801-6505
  • Fax: 705-801-6505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: