Healthcare Provider Details

I. General information

NPI: 1174909451
Provider Name (Legal Business Name): ANTONIO CLARENCE ELLZEY SR. NCC, LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2015
Last Update Date: 10/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9435 BORMET DR STE 5
MOKENA IL
60448-7401
US

IV. Provider business mailing address

9119S EXCHANGE AVE
CHICAGO IL
60617-4225
US

V. Phone/Fax

Practice location:
  • Phone: 708-995-7226
  • Fax:
Mailing address:
  • Phone: 773-768-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberEIN-27-4113346
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: