Provider Demographics
NPI:1043201023
Name:STICKNEY, ELLEN
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:
Last Name:STICKNEY
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 1:1835 MIRACLE MILE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-2807
Mailing Address - Country:US
Mailing Address - Phone:937-390-7960
Mailing Address - Fax:937-390-7971
Practice Address - Street 1:1835 MIRACLE MILE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2807
Practice Address - Country:US
Practice Address - Phone:937-390-7960
Practice Address - Fax:937-390-7971
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI00010491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0004519076OtherAETNA
OH000000004558OtherANTHEM