Provider Demographics
NPI:1558418939
Name:BLACK, ELLYN MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:ELLYN
Middle Name:MARIE
Last Name:BLACK
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 1:5005 N PIEDRAS ST
Mailing Address - Street 2:11 W FAMILY ADVOCACY
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79920-5001
Mailing Address - Country:US
Mailing Address - Phone:915-569-2800
Mailing Address - Fax:915-569-1553
Practice Address - Street 1:5005 N PIEDRAS ST
Practice Address - Street 2:11 W FAMILY ADVOCACY
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79920-5001
Practice Address - Country:US
Practice Address - Phone:915-569-2800
Practice Address - Fax:915-569-1553
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX263061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical