Provider Demographics
NPI:1619008505
Name:ELLIS, MARLENE S (LISW)
Entity Type:Individual
Prefix:MS
First Name:MARLENE
Middle Name:S
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-2954
Mailing Address - Country:US
Mailing Address - Phone:419-332-4722
Mailing Address - Fax:419-334-8590
Practice Address - Street 1:212 S PARK AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-2954
Practice Address - Country:US
Practice Address - Phone:419-332-4722
Practice Address - Fax:419-334-8590
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-0007955101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000372656OtherANTHEM
OH5889631OtherAETNA
OH000000372656OtherANTHEM