Healthcare Provider Details

I. General information

NPI: 1679007520
Provider Name (Legal Business Name): LENNEA ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 02/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 MACKEY PL STE 135
SHREVEPORT LA
71118-2528
US

IV. Provider business mailing address

6000 W 70TH ST APT 2501
SHREVEPORT LA
71129-2534
US

V. Phone/Fax

Practice location:
  • Phone: 318-220-8423
  • Fax:
Mailing address:
  • Phone: 318-820-7983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: