Provider Demographics
NPI:1598279853
Name:ELLIS, BRIAN TODD (LMSW)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:TODD
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LMSW
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 35944
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50315-0326
Mailing Address - Country:US
Mailing Address - Phone:515-333-9734
Mailing Address - Fax:
Practice Address - Street 1:1501 42ND ST
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1005
Practice Address - Country:US
Practice Address - Phone:515-333-9734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-24
Last Update Date:2017-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA087137104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker