Provider Demographics
NPI:1750458063
Name:ELLIS, ELIZABETH ELAINE (LISW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ELAINE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7715 AURORA DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-1601
Mailing Address - Country:US
Mailing Address - Phone:915-345-9972
Mailing Address - Fax:
Practice Address - Street 1:7950 MARNE RD
Practice Address - Street 2:
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905-3175
Practice Address - Country:US
Practice Address - Phone:762-408-2610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI 063071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical