Provider Demographics
NPI: | 1922010040 |
---|---|
Name: | FIELLMAN, ELLEN DENISE (LCSW) |
Entity Type: | Individual |
Prefix: | |
First Name: | ELLEN |
Middle Name: | DENISE |
Last Name: | FIELLMAN |
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: | 1430 OLIVE ST |
Mailing Address - Street 2: | SUITE 400 |
Mailing Address - City: | SAINT LOUIS |
Mailing Address - State: | MO |
Mailing Address - Zip Code: | 63103-2303 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 314-206-3405 |
Mailing Address - Fax: | 314-206-3992 |
Practice Address - Street 1: | 1430 OLIVE ST |
Practice Address - Street 2: | SUITE 400 |
Practice Address - City: | SAINT LOUIS |
Practice Address - State: | MO |
Practice Address - Zip Code: | 63103-2303 |
Practice Address - Country: | US |
Practice Address - Phone: | 314-206-3405 |
Practice Address - Fax: | 314-206-3992 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-08-13 |
Last Update Date: | 2013-01-16 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 069917-1 | 104100000X |
MO | 2012025911 | 1041C0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No | 104100000X | Behavioral Health & Social Service Providers | Social Worker |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 07300069917 | Medicaid | |
NY | 07300069917 | Medicaid |