Provider Demographics
NPI:1740292390
Name:ELLIS, DEBORAH S (LICSW)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:S
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 1:1130 TEN ROD RD
Mailing Address - Street 2:SUITE D-104
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-4161
Mailing Address - Country:US
Mailing Address - Phone:401-258-7511
Mailing Address - Fax:401-295-5575
Practice Address - Street 1:1130 TEN ROD RD
Practice Address - Street 2:SUITE D-104
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-4161
Practice Address - Country:US
Practice Address - Phone:401-295-5575
Practice Address - Fax:401-295-5552
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW014731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1033160OtherBEACON HEALTH STRATEGIES
RI410115OtherBLUE CHIP
RI21729-1OtherBLUE CROSS BLUE SHIELD OF
RI722607000OtherMAGELLAN