Provider Demographics
NPI:1841922200
Name:ELLIS, BRIANNA SUSAN
Entity type:Individual
Prefix:MS
First Name:BRIANNA
Middle Name:SUSAN
Last Name:ELLIS
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 1:976 UNIVERSITY DR SIDE A
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-5541
Mailing Address - Country:US
Mailing Address - Phone:309-645-7233
Mailing Address - Fax:
Practice Address - Street 1:976 UNIVERSITY DR SIDE A
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-5541
Practice Address - Country:US
Practice Address - Phone:309-645-7233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-25
Last Update Date:2022-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker