Provider Demographics
NPI:1952803231
Name:ELLIS, ANNALYSE (LMSW, CMHP, CAADC)
Entity Type:Individual
Prefix:
First Name:ANNALYSE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LMSW, CMHP, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 BARFIELD DR
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-9018
Mailing Address - Country:US
Mailing Address - Phone:269-948-8041
Mailing Address - Fax:
Practice Address - Street 1:500 BARFIELD DR
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058
Practice Address - Country:US
Practice Address - Phone:269-948-8041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-02
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
MI6801102389104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator