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NPI Code Detail

MEDICARE: LISA ELLIS

MEDICARE: LISA ELLIS
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
1103TC0700XClinical Psychologist01860MO

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1437247210
Entity Type Code : Individual
Provider Name (Legal Business Name) : LISA ELLIS
Provider Business Mailing Address
First Line : 5300 ARSENAL ST
Second Line : C166
City : SAINT LOUIS
State : MO
Zip : 63139-1463
Country : US
Telephone Number : 314-877-5789
Fax Number :
Provider Business Practice Location Address
First Line : 5300 ARSENAL ST
Second Line : C166
City : SAINT LOUIS
State : MO
Zip : 63139-1463
Country : US
Telephone Number : 314-877-5789
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/10/2006
Last Update Date : 08/11/2008

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Directions to “ LISA ELLIS ” Practice Location

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