Provider Demographics
NPI:1720188725
Name:ELLIS, SUSAN SHEREEN (LSCSW)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:SHEREEN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:MISS
Other - First Name:SUSAN
Other - Middle Name:SHEREEN
Other - Last Name:OMARKHAIL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:325 SW FRAZIER AVE
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66606-1963
Mailing Address - Country:US
Mailing Address - Phone:785-232-5005
Mailing Address - Fax:785-232-0160
Practice Address - Street 1:325 SW FRAZIER AVE
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606-1963
Practice Address - Country:US
Practice Address - Phone:785-232-5005
Practice Address - Fax:785-232-0160
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS36581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS70868OtherBLUE CROSS BLUE SHIELD