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NPI Code Detail

MEDICARE: DEONTRAE MARQUISE ELLIS LICDC

MEDICARE: DEONTRAE MARQUISE ELLIS LICDC
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
1101Y00000XCounselor
2101YA0400XAddiction (Substance Use Disorder) CounselorLICDC.151072OH

General Provider Information

NPI Number : 1548505860
Entity Type Code : Individual
Provider Name (Legal Business Name) : DEONTRAE MARQUISE ELLIS LICDC
Provider Business Mailing Address
First Line : 4600 MONTGOMERY RD STE 400
Second Line :
City : CINCINNATI
State : OH
Zip : 45212-2600
Country : US
Telephone Number : 513-873-1269
Fax Number :
Provider Business Practice Location Address
First Line : 201 N YELLOW SPRINGS ST
Second Line :
City : SPRINGFIELD
State : OH
Zip : 45504-2650
Country : US
Telephone Number : 833-510-4357
Fax Number : 513-881-7188
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/28/2012
Last Update Date : 10/24/2023

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Directions to “ DEONTRAE MARQUISE ELLIS LICDC” Practice Location

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