Provider Demographics
NPI:1295708063
Name:ELLIS, COLLEEN (LSCSW)
Entity type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 SW 29TH ST
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66611
Mailing Address - Country:US
Mailing Address - Phone:785-266-6806
Mailing Address - Fax:785-266-6546
Practice Address - Street 1:2201 SW 29TH ST
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66611
Practice Address - Country:US
Practice Address - Phone:785-266-6806
Practice Address - Fax:785-266-6546
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLSCSW6321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS011064OtherBCBS
KS011064OtherBCBS