Provider Demographics
NPI:1598195570
Name:ELLIS, KAREN (LCSW)
Entity Type:Individual
Prefix:
First Name:KAREN
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:PO BOX 195
Mailing Address - Street 2:
Mailing Address - City:HANNA
Mailing Address - State:WY
Mailing Address - Zip Code:82327-0195
Mailing Address - Country:US
Mailing Address - Phone:307-320-3082
Mailing Address - Fax:
Practice Address - Street 1:305 MAIN ST
Practice Address - Street 2:
Practice Address - City:HANNA
Practice Address - State:WY
Practice Address - Zip Code:82327
Practice Address - Country:US
Practice Address - Phone:307-320-3082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6722561-35011041C0700X
WYLCSW-10281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical