Provider Demographics
NPI:1407211782
Name:ELLIS, DIANTE
Entity Type:Individual
Prefix:
First Name:DIANTE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1049 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103-2114
Mailing Address - Country:US
Mailing Address - Phone:413-739-1100
Mailing Address - Fax:413-304-4666
Practice Address - Street 1:1049 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-2114
Practice Address - Country:US
Practice Address - Phone:413-739-1100
Practice Address - Fax:413-304-4666
Is Sole Proprietor?:No
Enumeration Date:2015-12-30
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2214421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110028120Medicaid
MAM21172Medicare UPIN