Provider Demographics
NPI:1437247210
Name:ELLIS, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 ARSENAL ST
Mailing Address - Street 2:C166
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-1463
Mailing Address - Country:US
Mailing Address - Phone:314-877-5789
Mailing Address - Fax:
Practice Address - Street 1:5300 ARSENAL ST
Practice Address - Street 2:C166
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-1463
Practice Address - Country:US
Practice Address - Phone:314-877-5789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01860103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499441608Medicaid
MO499441608Medicaid