Provider Demographics
NPI:1447238258
Name:ELLWOOD, AMY (MSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:ELLWOOD
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 FIRE MESA ST STE 180
Mailing Address - Street 2:FAMILY PRACTICE CENTER
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-9017
Mailing Address - Country:US
Mailing Address - Phone:702-992-6888
Mailing Address - Fax:702-992-6880
Practice Address - Street 1:2410 FIRE MESA ST
Practice Address - Street 2:#180, FAMILY PRACTICE CENTER
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-9016
Practice Address - Country:US
Practice Address - Phone:702-992-6888
Practice Address - Fax:702-992-6880
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV01405-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100500818Medicaid
NVWQBHV36011Medicare ID - Type Unspecified
NV100500818Medicaid