MEDICARE: MARIA ELLIS, LLC

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

General Provider Information

NPI Number	:	1134607203
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARIA ELLIS, LLC

Provider Business Mailing Address
First Line	:	3017 DRIFTWOOD WAY UNIT 3006
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34109-8981
Country	:	US
Telephone Number	:	702-715-2212
Fax Number	:

Provider Business Practice Location Address
First Line	:	3017 DRIFTWOOD WAY UNIT 3006
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34109-8981
Country	:	US
Telephone Number	:	702-715-2212
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MARIA ELLIS
Credential	:	LCSW
Telephone Number	:	702-715-2212

Provider Enumeration Date	:	08/01/2018
Last Update Date	:	08/01/2018

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