MEDICARE: LISA B 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	CSW002706	GA

General Provider Information

NPI Number	:	1609206507
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LISA B ELLIS, LLC

Provider Business Mailing Address
First Line	:	3635 THOMPSON MILL RD
Second Line	:
City	:	BUFORD
State	:	GA
Zip	:	30519-5448
Country	:	US
Telephone Number	:	404-401-7715
Fax Number	:	770-995-1959

Provider Business Practice Location Address
First Line	:	1400 BUFORD HWY
Second Line	:	STE G7
City	:	SUGARHILL
State	:	GA
Zip	:	30518-8721
Country	:	US
Telephone Number	:	404-401-7715
Fax Number	:	770-995-1959

Authorized Official
Title or Position	:	OWNER
Name	:	LISA B ELLIS
Credential	:	LCSW
Telephone Number	:	404-401-7715

Provider Enumeration Date	:	11/14/2013
Last Update Date	:	08/17/2022

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