Provider Demographics
NPI:1790158467
Name:ELLIS, SIERRA (LCSW)
Entity Type:Individual
Prefix:
First Name:SIERRA
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 578
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE WELLS
Mailing Address - State:CO
Mailing Address - Zip Code:80810-0578
Mailing Address - Country:US
Mailing Address - Phone:719-767-5661
Mailing Address - Fax:719-767-5098
Practice Address - Street 1:602 N 6TH ST W
Practice Address - Street 2:
Practice Address - City:CHEYENNE WELLS
Practice Address - State:CO
Practice Address - Zip Code:80810-5125
Practice Address - Country:US
Practice Address - Phone:719-767-5661
Practice Address - Fax:719-767-5098
Is Sole Proprietor?:No
Enumeration Date:2015-11-03
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12860104100000X, 1041C0700X
MSC101751041C0700X
AL5048C1041C0700X
171M00000X
COCSW.099284321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator