Provider Demographics
NPI:1497090724
Name:ELLIS, DARA (LCSW)
Entity Type:Individual
Prefix:
First Name:DARA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 W WILLIAM CANNON DR APT B203
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-5145
Mailing Address - Country:US
Mailing Address - Phone:512-537-6322
Mailing Address - Fax:
Practice Address - Street 1:8400 N MOPAC EXPY
Practice Address - Street 2:SUITE 302
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8328
Practice Address - Country:US
Practice Address - Phone:512-537-6322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX542101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical