Healthcare Provider Details

I. General information

NPI: 1992642821
Provider Name (Legal Business Name): ELLIS JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7035 THICKETT DR
INDIANAPOLIS IN
46254-5645
US

IV. Provider business mailing address

7035 THICKETT DR APT 1B
INDIANAPOLIS IN
46254-4628
US

V. Phone/Fax

Practice location:
  • Phone: 317-601-4980
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: