Provider Demographics
NPI:1659599629
Name:ELLIS, MARCIA NICHOLS (PLPC)
Entity Type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:NICHOLS
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2764 S MARLBOROUGH AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-3061
Mailing Address - Country:US
Mailing Address - Phone:417-886-1594
Mailing Address - Fax:
Practice Address - Street 1:1722 S. GLENSTONE AVE
Practice Address - Street 2:STE H
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804
Practice Address - Country:US
Practice Address - Phone:417-881-9518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007010499101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional