Provider Demographics
NPI:1861669566
Name:ELLISON, JUDITH (LCSW)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:ELLISON
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 1:3738 CHOUTEAU AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2546
Mailing Address - Country:US
Mailing Address - Phone:314-772-8801
Mailing Address - Fax:314-772-7988
Practice Address - Street 1:3738 CHOUTEAU AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2546
Practice Address - Country:US
Practice Address - Phone:314-772-8801
Practice Address - Fax:314-772-7988
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0051171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical