Provider Demographics
NPI:1629292032
Name:ELLIS, LESLEY ANN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:LESLEY
Middle Name:ANN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12138 CENTRAL AVENUE
Mailing Address - Street 2:#662
Mailing Address - City:MITCHELLVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20721
Mailing Address - Country:US
Mailing Address - Phone:301-336-3242
Mailing Address - Fax:
Practice Address - Street 1:12138 CENTRAL AVENUE
Practice Address - Street 2:#662
Practice Address - City:MITCHELLVILLE
Practice Address - State:MD
Practice Address - Zip Code:20721
Practice Address - Country:US
Practice Address - Phone:301-336-3242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500786271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical