Provider Demographics
NPI:1760726236
Name:ELLIS, MEGHANN DEVINE
Entity Type:Individual
Prefix:MISS
First Name:MEGHANN
Middle Name:DEVINE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 HARDY ST APT 2
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-5241
Mailing Address - Country:US
Mailing Address - Phone:860-748-2584
Mailing Address - Fax:
Practice Address - Street 1:12 METHUEN ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840-1700
Practice Address - Country:US
Practice Address - Phone:978-857-7162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1171391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical