Provider Demographics
NPI:1831303189
Name:ELLIS, SUE
Entity Type:Individual
Prefix:MS
First Name:SUE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SUE
Other - Middle Name:C
Other - Last Name:SCHEFFLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW,
Mailing Address - Street 1:30 N MICHIGAN AVE
Mailing Address - Street 2:1016
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3402
Mailing Address - Country:US
Mailing Address - Phone:312-782-4840
Mailing Address - Fax:
Practice Address - Street 1:30 N MICHIGAN AVE
Practice Address - Street 2:1016
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3402
Practice Address - Country:US
Practice Address - Phone:312-782-4840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490001961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149000196OtherL.C.S.W.
IL149000196OtherL.C.S.W.