Provider Demographics
NPI:1205993011
Name:ELLIS, STEPHEN DAY (MSW,PHD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:DAY
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MSW,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1622 NAUDAIN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1521
Mailing Address - Country:US
Mailing Address - Phone:215-893-0646
Mailing Address - Fax:215-732-8454
Practice Address - Street 1:313 S 16TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-4908
Practice Address - Country:US
Practice Address - Phone:215-893-0646
Practice Address - Fax:215-732-8454
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW000931L1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA600877Medicare ID - Type Unspecified