Provider Demographics
NPI:1790129195
Name:ELLIS, NICOLA (LCSW)
Entity Type:Individual
Prefix:
First Name:NICOLA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 361
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-0361
Mailing Address - Country:US
Mailing Address - Phone:773-793-7147
Mailing Address - Fax:
Practice Address - Street 1:2635 S WABASH AVE FL 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616
Practice Address - Country:US
Practice Address - Phone:773-793-7147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-29
Last Update Date:2018-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0083401041C0700X
IL1490182061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical