Provider Demographics
NPI:1245397256
Name:ELLIS, KATHRYN GAIL (MSW)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:GAIL
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 S LINDBERGH BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-1372
Mailing Address - Country:US
Mailing Address - Phone:314-965-1942
Mailing Address - Fax:314-835-1580
Practice Address - Street 1:3701 S LINDBERGH BLVD STE 205
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1372
Practice Address - Country:US
Practice Address - Phone:314-965-1942
Practice Address - Fax:314-835-1580
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0001801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical