Active NPI
Mavonna Marie Ellis, PHD
- Mental Health Counselor
- Stillwater, OK
National Provider Identifier
1124064233
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Mental Health Counselor
- License
- 3974
- Practice address
- 1616 S August St
Stillwater, OK 74074-1837 - Phone
- (405) 564-0656
- NPI assigned
- Jun 20, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Mental Health Counselor | 101YM0800X | 3974 | OK | Primary |
Addresses
Primary practice location
1616 S August St
Stillwater, OK 74074-1837
Mailing address
1616 S August St
Stillwater, OK 74074-1837
Phone (405) 564-0656
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 3974 | OK | MD | Physical Therapy Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1150761600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1224028800000",
"number": "1124064233",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1616 S AUGUST ST",
"city": "STILLWATER",
"state": "OK",
"postal_code": "740741837",
"telephone_number": "405-564-0656"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1616 S AUGUST ST",
"city": "STILLWATER",
"state": "OK",
"postal_code": "740741837",
"telephone_number": "405-564-0656"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ELLIS",
"first_name": "MAVONNA",
"middle_name": "MARIE",
"name_prefix": "Dr.",
"credential": "PHD",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-06-20",
"last_updated": "2008-10-15",
"status": "A"
},
"taxonomies": [
{
"code": "101YM0800X",
"taxonomy_group": "",
"desc": "Counselor, Mental Health",
"state": "OK",
"license": "3974",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Stillwater, OK
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 15, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.