Provider Demographics
NPI:1083842280
Name:ELLIS, LISA (LSCSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 SW 29TH ST
Mailing Address - Street 2:STE 108
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66614-2015
Mailing Address - Country:US
Mailing Address - Phone:785-271-6551
Mailing Address - Fax:785-271-6553
Practice Address - Street 1:3601 SW 29TH ST
Practice Address - Street 2:STE 108
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66614-2015
Practice Address - Country:US
Practice Address - Phone:785-271-6551
Practice Address - Fax:785-271-6553
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS40311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS110661007OtherMEDICARE PTAN
KS200613480BMedicaid