Provider Demographics
NPI:1508542499
Name:ELLIS, MELLISA ANN (LSW)
Entity Type:Individual
Prefix:
First Name:MELLISA
Middle Name:ANN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:MELLISA
Other - Middle Name:ANN
Other - Last Name:ROUNDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24 CHEVY CHASE BUILDING
Mailing Address - Street 2:
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033
Mailing Address - Country:US
Mailing Address - Phone:607-201-9635
Mailing Address - Fax:
Practice Address - Street 1:24 CHEVY CHASE BUILDING
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033
Practice Address - Country:US
Practice Address - Phone:607-201-9635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114949-01104100000X
PASW139726104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker