Provider Demographics
NPI:1891261855
Name:ELLISON, MARC R (LICSWA)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:R
Last Name:ELLISON
Suffix:
Gender:M
Credentials:LICSWA
Other - Prefix:
Other - First Name:M
Other - Middle Name:ELI
Other - Last Name:ELLISON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSWA
Mailing Address - Street 1:414 FRONT ST N
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-2914
Mailing Address - Country:US
Mailing Address - Phone:425-392-6367
Mailing Address - Fax:425-391-4971
Practice Address - Street 1:414 FRONT ST N
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2914
Practice Address - Country:US
Practice Address - Phone:425-392-6367
Practice Address - Fax:425-391-4971
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC605072501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical