Healthcare Provider Details

I. General information

NPI: 1740538065
Provider Name (Legal Business Name): DANIEL ELLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 08/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 W MULBERRY ST
WATSEKA IL
60970-1568
US

IV. Provider business mailing address

323 W MULBERRY ST PO BOX 322
WATSEKA IL
60970-1568
US

V. Phone/Fax

Practice location:
  • Phone: 815-432-5241
  • Fax: 815-432-4537
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: