Provider Demographics
NPI:1215017009
Name:ELLIS, CHARLES (LCSW-C)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-3121
Mailing Address - Country:US
Mailing Address - Phone:410-383-8300
Mailing Address - Fax:410-383-3160
Practice Address - Street 1:5130 S. PECOS ROAD
Practice Address - Street 2:SUITE 2B
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120
Practice Address - Country:US
Practice Address - Phone:702-560-5973
Practice Address - Fax:888-753-3302
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 191431041C0700X
NV5980-C1041C0700X
MD269601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical