Provider Demographics
NPI:1477854313
Name:ELLIS, WILLIAM GRANT (LPC)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:GRANT
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:937 GARDENVIEW OFFICE PKWY
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5917
Mailing Address - Country:US
Mailing Address - Phone:314-983-0070
Mailing Address - Fax:314-983-0077
Practice Address - Street 1:937 GARDENVIEW OFFICE PKWY
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-5917
Practice Address - Country:US
Practice Address - Phone:314-983-0070
Practice Address - Fax:314-983-0077
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-09
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010033598101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional