Provider Demographics
NPI:1477183754
Name:ELLIS, JAMES BRADLEY (LICSW)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:BRADLEY
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 67TH ST NW
Mailing Address - Street 2:
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35967-8306
Mailing Address - Country:US
Mailing Address - Phone:334-425-4295
Mailing Address - Fax:
Practice Address - Street 1:1306 67TH ST NW
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35967-8306
Practice Address - Country:US
Practice Address - Phone:334-425-4295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-25
Last Update Date:2020-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4301C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty