Provider Demographics
NPI:1770527426
Name:ELLIS, DIANE MARLENE (PSYD, LP)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:MARLENE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:MS
Other - First Name:DIANE
Other - Middle Name:MARLENE
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1300 E BRADFORD PKWY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4264
Mailing Address - Country:US
Mailing Address - Phone:417-761-5000
Mailing Address - Fax:417-761-5065
Practice Address - Street 1:323 E GRAND ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-1447
Practice Address - Country:US
Practice Address - Phone:417-761-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007033885103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497428003Medicaid
MO497428003OtherMO HEALTHNET DIVISION