Provider Demographics
NPI:1811249048
Name:ELLIS, CRYSTAL DAWN (LSCSW)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DAWN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:DAWN
Other - Last Name:WITTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5399 HWY 43 BLDG B
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-4927
Mailing Address - Country:US
Mailing Address - Phone:913-444-9756
Mailing Address - Fax:
Practice Address - Street 1:5399 HWY 43 BLDG B
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4927
Practice Address - Country:US
Practice Address - Phone:913-444-9756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK211131041C0700X
MO20220213601041C0700X
KS47611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
16130914OtherCAQH