Provider Demographics
NPI:1720385552
Name:ELLISON, MYKAH (LMSW)
Entity Type:Individual
Prefix:
First Name:MYKAH
Middle Name:
Last Name:ELLISON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 PICKWICK ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:TN
Mailing Address - Zip Code:38372-3519
Mailing Address - Country:US
Mailing Address - Phone:731-925-5054
Mailing Address - Fax:731-925-5699
Practice Address - Street 1:1410 PICKWICK ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:TN
Practice Address - Zip Code:38372-3519
Practice Address - Country:US
Practice Address - Phone:731-925-5054
Practice Address - Fax:731-925-5699
Is Sole Proprietor?:No
Enumeration Date:2011-02-14
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN60281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ010331Medicaid
TNQ010331Medicaid