Healthcare Provider Details

I. General information

NPI: 1508561036
Provider Name (Legal Business Name): LACIE ELLITHORPE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 04/03/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1170 CHARTER DR STE B
FLINT MI
48532-3587
US

IV. Provider business mailing address

1170 CHARTER DR STE B
FLINT MI
48532-3587
US

V. Phone/Fax

Practice location:
  • Phone: 810-877-6343
  • Fax: 810-674-0044
Mailing address:
  • Phone: 810-877-6343
  • Fax: 810-674-0044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851115582
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: