MEDICARE: MRS. KIMBERLY Y ELLIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	373H00000X	Day Training/Habilitation Specialist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0	OTHER		NONE

General Provider Information

NPI Number	:	1023531340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLY Y ELLIS

Provider Business Mailing Address
First Line	:	7365 GRANVILLE DR
Second Line	:
City	:	MANSFIELD
State	:	TX
Zip	:	76063-4647
Country	:	US
Telephone Number	:	469-657-9165
Fax Number	:

Provider Business Practice Location Address
First Line	:	7365 GRANVILLE DR
Second Line	:
City	:	MANSFIELD
State	:	TX
Zip	:	76063-4647
Country	:	US
Telephone Number	:	469-657-9165
Fax Number	:	469-657-9165

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2017
Last Update Date	:	07/18/2017

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