Provider Demographics
NPI:1851157945
Name:ELLIS, MEGAN
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
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 1:7869 FENWICK ST
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-2703
Mailing Address - Country:US
Mailing Address - Phone:270-312-0739
Mailing Address - Fax:
Practice Address - Street 1:217 MIRACLE STRIP PKWY SE STE 121
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-5819
Practice Address - Country:US
Practice Address - Phone:850-861-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW195801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical