Healthcare Provider Details

I. General information

NPI: 1730625294
Provider Name (Legal Business Name): STEPHANIE ANN ELLIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 EASTVIEW AVE
KATHLEEN GA
31047-2554
US

IV. Provider business mailing address

5201 GREAT AMERICA PKWY STE 320
SANTA CLARA CA
95054-1140
US

V. Phone/Fax

Practice location:
  • Phone: 919-986-2112
  • Fax:
Mailing address:
  • Phone: 951-387-4891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number009622
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number83676
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC009955
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: