Provider Demographics
NPI:1245680925
Name:ELLIS, AMANDA (LICSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2960 SNELLING AVE N
Mailing Address - Street 2:STE 210
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-2458
Mailing Address - Country:US
Mailing Address - Phone:651-217-8600
Mailing Address - Fax:
Practice Address - Street 1:2960 SNELLING AVE N
Practice Address - Street 2:STE 210
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-2458
Practice Address - Country:US
Practice Address - Phone:651-217-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-14
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN252581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH300322582OtherNGS MEDICARE