Provider Demographics
NPI:1871984476
Name:ELLISON, TIANA
Entity type:Individual
Prefix:
First Name:TIANA
Middle Name:
Last Name:ELLISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 S 3RD ST
Mailing Address - Street 2:PO BOX 351
Mailing Address - City:GREYBULL
Mailing Address - State:WY
Mailing Address - Zip Code:82426
Mailing Address - Country:US
Mailing Address - Phone:307-568-2020
Mailing Address - Fax:
Practice Address - Street 1:1114 LANE 12
Practice Address - Street 2:
Practice Address - City:LOVELL
Practice Address - State:WY
Practice Address - Zip Code:82431-9555
Practice Address - Country:US
Practice Address - Phone:307-568-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-18
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-873101YM0800X
WYLPC-1623101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health