Provider Demographics
NPI:1649306317
Name:PEDERSON-LEWIS, ELLEN CLAIRE (LCSW)
Entity type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:CLAIRE
Last Name:PEDERSON-LEWIS
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 1:7717 N BOYD WAY
Mailing Address - Street 2:
Mailing Address - City:FOX POINT
Mailing Address - State:WI
Mailing Address - Zip Code:53217-3210
Mailing Address - Country:US
Mailing Address - Phone:414-690-2197
Mailing Address - Fax:
Practice Address - Street 1:675 N BROOKFIELD RD
Practice Address - Street 2:STE 101
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-5858
Practice Address - Country:US
Practice Address - Phone:262-641-9300
Practice Address - Fax:262-641-9307
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1679-1231041C0700X
WI401-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39296900Medicaid