Provider Demographics
NPI:1134631757
Name:ELLIS, KERRY (LCSW-C)
Entity type:Individual
Prefix:MR
First Name:KERRY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260A HILLTOP LN APT 102
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-5809
Mailing Address - Country:US
Mailing Address - Phone:410-714-2626
Mailing Address - Fax:
Practice Address - Street 1:1111 BENFIELD BLVD STE 104
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-3003
Practice Address - Country:US
Practice Address - Phone:410-714-2626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-05
Last Update Date:2017-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD208291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty