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General NPI Number Information
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NPI Number | 1215175591
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Entity Type | Individual
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Provider Name | LAWRENCE EUGENE ELLIS LADC
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Gender | Male
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Dates
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Enumeration Date | 01/26/2009
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Last Update Date | 01/26/2009
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Provider Practice Location Address
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Address Line | 2401 N.W. 39TH I 44 SERVICE RD SUITE 103
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City | OKLAHOMA CITY
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State | OK
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Zip | 73112-8739
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Country | US
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Telephone | 405-557-1655
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Fax |
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Provider Business Mailing Address
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Address Line | 1308 NE 43RD ST
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City | OKLAHOMA CITY
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State | OK
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Zip | 73111-5853
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Country | US
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Telephone | 405-824-5066
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 366
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License Number State | OK
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