Provider Demographics
NPI:1841652567
Name:ELLIS, SAMANTHA MICHELLE (BA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MICHELLE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11097 SE 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-7640
Mailing Address - Country:US
Mailing Address - Phone:971-401-0364
Mailing Address - Fax:
Practice Address - Street 1:11097 SE 21ST AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7640
Practice Address - Country:US
Practice Address - Phone:971-401-0364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG 60478731104100000X
ORTHW000002555175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker