Healthcare Provider Details

I. General information

NPI: 1063496560
Provider Name (Legal Business Name): SANDY S. ELLIS MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 N WALNUT ST
BUFFALO MO
65622-7449
US

IV. Provider business mailing address

202 N WALNUT ST P.O. BOX 148
BUFFALO MO
65622-7449
US

V. Phone/Fax

Practice location:
  • Phone: 417-345-8855
  • Fax: 417-345-8855
Mailing address:
  • Phone: 417-345-8855
  • Fax: 417-345-8855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW003530
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: