Provider Demographics
NPI:1912045386
Name:ELLIS, MAUREEN ANN (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MAUREEN
Middle Name:ANN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12054 DEPAUL HILLS DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-3511
Mailing Address - Country:US
Mailing Address - Phone:314-298-0808
Mailing Address - Fax:
Practice Address - Street 1:12054 DEPAUL HILLS DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-3511
Practice Address - Country:US
Practice Address - Phone:314-298-0808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO001878104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical