Provider Demographics
NPI:1336183086
Name:ELLISOR, PATRICIA ANN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:ANN
Last Name:ELLISOR
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:PO BOX 1328
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81302-1328
Mailing Address - Country:US
Mailing Address - Phone:970-259-2162
Mailing Address - Fax:970-247-5255
Practice Address - Street 1:281 SAWYER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81303-3409
Practice Address - Country:US
Practice Address - Phone:970-259-2162
Practice Address - Fax:970-247-5255
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COS78972Medicare UPIN
CO805146Medicare ID - Type Unspecified