Provider Demographics
NPI:1477276897
Name:ELLIS-LIVELY, ANGELA M
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:ELLIS-LIVELY
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 1:101 BILL BAKER WAY
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-1505
Mailing Address - Country:US
Mailing Address - Phone:304-252-8324
Mailing Address - Fax:
Practice Address - Street 1:28 MALLARD CT
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3664
Practice Address - Country:US
Practice Address - Phone:304-252-8409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-21
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP00944946104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker