MEDICARE: DR. KEIAH ELLIS PH.D.

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	101YP1600X	Pastoral Counselor

General Provider Information

NPI Number	:	1114428091
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEIAH ELLIS PH.D.

Provider Business Mailing Address
First Line	:	7832 OAK CREEK TRL
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71129-8811
Country	:	US
Telephone Number	:	318-344-3770
Fax Number	:

Provider Business Practice Location Address
First Line	:	7832 OAK CREEK TRL
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71129-8811
Country	:	US
Telephone Number	:	318-344-3770
Fax Number	:

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

Provider Enumeration Date	:	02/26/2018
Last Update Date	:	02/26/2018

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Directions to “ DR. KEIAH ELLIS PH.D.” Practice Location

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