Provider Demographics
NPI:1760821011
Name:ELLIS, LINDA SUSAN (LLBSW)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:SUSAN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LLBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 CORUNNA RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-3254
Mailing Address - Country:US
Mailing Address - Phone:810-235-6812
Mailing Address - Fax:810-234-7022
Practice Address - Street 1:2830 CORUNNA RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-3254
Practice Address - Country:US
Practice Address - Phone:810-235-6812
Practice Address - Fax:810-234-7022
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802087444171M00000X
MI6401015955101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator