Active NPI
Tabatha Ellis, PRSS
- Peer Specialist
- Princeton, WV
National Provider Identifier
1235950643
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Peer Specialist
- License
- 24-989
- Practice address
- 200 12TH Street Ext
Princeton, WV 24740-2329 - Phone
- (304) 732-6043
- NPI assigned
- Oct 18, 2024
- Sex
- Female
- Sole proprietor
- Yes
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 |
|---|---|---|---|---|
| Peer Specialist | 175T00000X | 24-989 | WV | Primary |
Addresses
Primary practice location
200 12TH Street Ext
Princeton, WV 24740-2329
Mailing address
200 12TH Street Ext
Princeton, WV 24740-2329
Phone (304) 732-6043
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
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 24-989 | WV | MD | Peer Specialist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1729209600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1729209600000",
"number": "1235950643",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "200 12TH STREET EXT",
"city": "PRINCETON",
"state": "WV",
"postal_code": "247402329",
"telephone_number": "304-732-6043"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "200 12TH STREET EXT",
"city": "PRINCETON",
"state": "WV",
"postal_code": "247402329",
"telephone_number": "304-732-6043"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ELLIS",
"first_name": "TABATHA",
"credential": "PRSS",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2024-10-18",
"last_updated": "2024-10-18",
"certification_date": "2024-10-18",
"status": "A"
},
"taxonomies": [
{
"code": "175T00000X",
"taxonomy_group": "",
"desc": "Peer Specialist",
"state": "WV",
"license": "24-989",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Princeton, WV
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 18, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.