Provider Demographics
NPI:1629193982
Name:ELLIS, DEBBIE L (LSW)
Entity Type:Individual
Prefix:MRS
First Name:DEBBIE
Middle Name:L
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4212 OLD GRAND AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-2708
Mailing Address - Country:US
Mailing Address - Phone:847-336-5621
Mailing Address - Fax:847-336-2594
Practice Address - Street 1:4212 OLD GRAND AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-2708
Practice Address - Country:US
Practice Address - Phone:847-336-5621
Practice Address - Fax:847-336-2594
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker