Provider Demographics
NPI:1043921232
Name:ELLUL, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:ELLUL
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 1:11011 W NORTH AVE APT 112
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2275
Mailing Address - Country:US
Mailing Address - Phone:231-735-4585
Mailing Address - Fax:
Practice Address - Street 1:10150 W NATIONAL AVE STE 390
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2145
Practice Address - Country:US
Practice Address - Phone:414-545-4430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical