Healthcare Provider Details

I. General information

NPI: 1609453307
Provider Name (Legal Business Name): ELLIS THERAPEUTIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2021
Last Update Date: 03/27/2021
Certification Date: 03/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16116 INVERRARY LN
BLOOMINGTON IL
61705-5580
US

IV. Provider business mailing address

16116 INVERRARY LN
BLOOMINGTON IL
61705-5580
US

V. Phone/Fax

Practice location:
  • Phone: 309-830-3968
  • Fax:
Mailing address:
  • Phone: 309-830-3968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: THELMA CARPENTER-ELLIS
Title or Position: CEO/OWNER
Credential:
Phone: 309-830-3968