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NPI Code Detail

MEDICARE: MR. ANTONIO CLARENCE ELLZEY SR. NCC, LCPC

MEDICARE: MR. ANTONIO CLARENCE ELLZEY SR. NCC, LCPC
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
1101YP2500XProfessional CounselorEIN-27-4113346IL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11205137346OTHERILGROUP NPI

General Provider Information

NPI Number : 1174909451
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. ANTONIO CLARENCE ELLZEY SR. NCC, LCPC
Provider Business Mailing Address
First Line : 9119S EXCHANGE AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60617-4225
Country : US
Telephone Number : 773-768-5000
Fax Number :
Provider Business Practice Location Address
First Line : 9435 BORMET DR STE 5
Second Line :
City : MOKENA
State : IL
Zip : 60448-7401
Country : US
Telephone Number : 708-995-7226
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/10/2015
Last Update Date : 10/28/2015

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