Provider Demographics
NPI:1982091690
Name:ELLIS, DIANE CAROL (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:CAROL
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5527 W MARCONI AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-2402
Mailing Address - Country:US
Mailing Address - Phone:602-329-7938
Mailing Address - Fax:602-307-5021
Practice Address - Street 1:5527 W MARCONI AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-2402
Practice Address - Country:US
Practice Address - Phone:602-329-7938
Practice Address - Fax:602-307-5021
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-20
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-28551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical