Provider Demographics
NPI:1326077652
Name:ELLISON, DEBRA RAE (MSW, LICSW)
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:RAE
Last Name:ELLISON
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:MS
Other - First Name:DEBRA
Other - Middle Name:RAE
Other - Last Name:CULVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2407
Mailing Address - Country:US
Mailing Address - Phone:218-728-4491
Mailing Address - Fax:218-728-4404
Practice Address - Street 1:325 11TH AVE
Practice Address - Street 2:
Practice Address - City:TWO HARBORS
Practice Address - State:MN
Practice Address - Zip Code:55616-1300
Practice Address - Country:US
Practice Address - Phone:218-834-5520
Practice Address - Fax:218-834-4264
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN868021300Medicaid
MN868021300Medicaid