Provider Demographics
NPI:1902503014
Name:ELLINGER, MATTHEW ALLAN JR
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:ALLAN
Last Name:ELLINGER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3919 PERRIN CENTRAL BLVD APT 708
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-2759
Mailing Address - Country:US
Mailing Address - Phone:210-548-6744
Mailing Address - Fax:
Practice Address - Street 1:9314 RYDER DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78254-2000
Practice Address - Country:US
Practice Address - Phone:726-800-6773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX44114057106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician