Healthcare Provider Details

I. General information

NPI: 1922010040
Provider Name (Legal Business Name): ELLEN DENISE FIELLMAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 01/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 OLIVE ST SUITE 400
SAINT LOUIS MO
63103-2303
US

IV. Provider business mailing address

1430 OLIVE ST SUITE 400
SAINT LOUIS MO
63103-2303
US

V. Phone/Fax

Practice location:
  • Phone: 314-206-3405
  • Fax: 314-206-3992
Mailing address:
  • Phone: 314-206-3405
  • Fax: 314-206-3992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number069917-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2012025911
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: