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Provider Information for 1174909451


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Mr. ANTONIO CLARENCE ELLZEY Sr. NCC, LCPC


Sex: Male

NPI: 1174909451
Last Updated: 2015-10-28
Certification Date:

Details

NameValue
NPI1174909451
Enumeration Date2015-08-10
NPI TypeNPI-1 Individual
Sole ProprietorNO
StatusActive
Mailing Address 9119S EXCHANGE AVE
CHICAGO, IL 60617-4225
United States

Phone: 773-768-5000 | Fax:
 
Primary Practice Address 9435 BORMET DR STE 5
MOKENA, IL 60448-7401
United States

Phone: 708-995-7226 | Fax:
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
Other (non-Medicare)IL1205137346Group NPI
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
Yes 101YP2500X - Counselor - ProfessionalILEIN-27-4113346