Healthcare Provider Details

I. General information

NPI: 1730835679
Provider Name (Legal Business Name): ELLA DAVERN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 06/21/2026
Certification Date: 06/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4933 GEORGE FERNANDEZ DR
EL PASO TX
79938-8900
US

IV. Provider business mailing address

108 PALMETTO PARK BLVD STE D
LEXINGTON SC
29072-7969
US

V. Phone/Fax

Practice location:
  • Phone: 864-684-8029
  • Fax:
Mailing address:
  • Phone: 803-399-9333
  • Fax: 803-808-5392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10064
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number98373
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: