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:
Certification Date:
Details
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NPI | 1174909451 | ||||||||
Enumeration Date | 2015-08-10 | ||||||||
NPI Type | NPI-1 Individual | ||||||||
Sole Proprietor | NO | ||||||||
Status | Active | ||||||||
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: | ||||||||
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