Provider Demographics
NPI:1417653650
Name:ELLIE MENTAL HEALTH OF DES MOINES PC
Entity Type:Organization
Organization Name:ELLIE MENTAL HEALTH OF DES MOINES PC
Other - Org Name:ELLIE MENTAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:TIERNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-855-3549
Mailing Address - Street 1:12247 STRATFORD DR
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-8147
Mailing Address - Country:US
Mailing Address - Phone:515-393-6702
Mailing Address - Fax:
Practice Address - Street 1:12247 STRATFORD DR
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8147
Practice Address - Country:US
Practice Address - Phone:515-393-6702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-31
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty