Provider Demographics
NPI:1063496560
Name:ELLIS, SANDY S (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:SANDY
Middle Name:S
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 N WALNUT ST
Mailing Address - Street 2:P.O. BOX 148
Mailing Address - City:BUFFALO
Mailing Address - State:MO
Mailing Address - Zip Code:65622-7449
Mailing Address - Country:US
Mailing Address - Phone:417-345-8855
Mailing Address - Fax:417-345-8855
Practice Address - Street 1:202 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MO
Practice Address - Zip Code:65622-7449
Practice Address - Country:US
Practice Address - Phone:417-345-8855
Practice Address - Fax:417-345-8855
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOSW0035301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical