Provider Demographics
NPI:1871645655
Name:ELLENWOOD, STEVEN LOUIS (LMSW)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:LOUIS
Last Name:ELLENWOOD
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11920 EDEN TRL
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:MI
Mailing Address - Zip Code:48822-9621
Mailing Address - Country:US
Mailing Address - Phone:517-930-0898
Mailing Address - Fax:
Practice Address - Street 1:11920 EDEN TRL
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:MI
Practice Address - Zip Code:48822-9621
Practice Address - Country:US
Practice Address - Phone:517-930-0898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010581361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION65180Medicare PIN