Provider Demographics
NPI:1811949142
Name:ELLIS, TIM (LCSW)
Entity type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3651 SHEPHERDSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-9511
Mailing Address - Country:US
Mailing Address - Phone:270-378-0230
Mailing Address - Fax:
Practice Address - Street 1:3651 SHEPHERDSVILLE RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-9511
Practice Address - Country:US
Practice Address - Phone:270-378-0230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY12841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0500027Medicare PIN
KY0500907Medicare PIN
KYP20821Medicare UPIN