Provider Demographics
NPI:1033594775
Name:ELLIS, NAYIVE (LSCSW)
Entity Type:Individual
Prefix:
First Name:NAYIVE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:NAYIVE
Other - Middle Name:
Other - Last Name:AVELAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:104 S. MAIN
Mailing Address - Street 2:PO BOX 637
Mailing Address - City:JOHNSON
Mailing Address - State:KS
Mailing Address - Zip Code:67855-0637
Mailing Address - Country:US
Mailing Address - Phone:620-952-1738
Mailing Address - Fax:620-492-3316
Practice Address - Street 1:104 S. MAIN STREET
Practice Address - Street 2:
Practice Address - City:JOHNSON
Practice Address - State:KS
Practice Address - Zip Code:67855
Practice Address - Country:US
Practice Address - Phone:620-952-1738
Practice Address - Fax:620-492-3316
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-23
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS9639104100000X
KS47661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201119110BMedicaid