Provider Demographics
NPI:1245776707
Name:LEVINE, ELLEN L (LCSW)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:L
Last Name:LEVINE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4130 LINDELL BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2914
Mailing Address - Country:US
Mailing Address - Phone:314-535-5600
Mailing Address - Fax:314-535-6037
Practice Address - Street 1:4130 LINDELL BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2914
Practice Address - Country:US
Practice Address - Phone:314-535-5600
Practice Address - Fax:314-535-6037
Is Sole Proprietor?:No
Enumeration Date:2017-01-09
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110290591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2011029059OtherLCSW