MEDICARE: SANDY S. ELLIS MSW, LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW003530	MO

General Provider Information

NPI Number	:	1063496560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDY S. ELLIS MSW, LCSW

Provider Business Mailing Address
First Line	:	202 N WALNUT ST
Second Line	:	P.O. BOX 148
City	:	BUFFALO
State	:	MO
Zip	:	65622-7449
Country	:	US
Telephone Number	:	417-345-8855
Fax Number	:	417-345-8855

Provider Business Practice Location Address
First Line	:	202 N WALNUT ST
Second Line	:
City	:	BUFFALO
State	:	MO
Zip	:	65622-7449
Country	:	US
Telephone Number	:	417-345-8855
Fax Number	:	417-345-8855

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	07/08/2007

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