Healthcare Provider Details

I. General information

NPI: 1649017815
Provider Name (Legal Business Name): ELLEN SIBLEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2024
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 FENTRESS BLVD
DAYTONA BEACH FL
32114-1214
US

IV. Provider business mailing address

728 FENTRESS BLVD
DAYTONA BEACH FL
32114-1214
US

V. Phone/Fax

Practice location:
  • Phone: 386-272-7440
  • Fax: 386-204-0948
Mailing address:
  • Phone: 386-272-7440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW25718
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: