Healthcare Provider Details

I. General information

NPI: 1245680925
Provider Name (Legal Business Name): AMANDA ELLIS LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 METRO BLVD STE 335
EDINA MN
55439-2356
US

IV. Provider business mailing address

7400 METRO BLVD STE 335
EDINA MN
55439-2356
US

V. Phone/Fax

Practice location:
  • Phone: 651-217-8600
  • Fax:
Mailing address:
  • Phone: 651-217-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number25258
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: