Provider Demographics
NPI:1801534029
Name:MARTY, ELLIE
Entity type:Individual
Prefix:
First Name:ELLIE
Middle Name:
Last Name:MARTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8803 FARMSTEAD AVE
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-8836
Mailing Address - Country:US
Mailing Address - Phone:612-281-8303
Mailing Address - Fax:
Practice Address - Street 1:8803 FARMSTEAD AVE
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8836
Practice Address - Country:US
Practice Address - Phone:612-281-8303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22336104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker