Healthcare Provider Details

I. General information

NPI: 1154255131
Provider Name (Legal Business Name): ETHEL ELLIS CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7426 US HIGHWAY 42 STE 106
FLORENCE KY
41042-2056
US

IV. Provider business mailing address

112 EASTERN AVE
ELSMERE KY
41018-1920
US

V. Phone/Fax

Practice location:
  • Phone: 859-282-0119
  • Fax: 859-282-8018
Mailing address:
  • Phone: 859-282-0119
  • Fax: 859-282-8018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberCSW00001070
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: