Healthcare Provider Details

I. General information

NPI: 1982638409
Provider Name (Legal Business Name): ELLEN J STEVENS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 01/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 DOOLITTLE DR
ELLSWORTH AFB SD
57706-4821
US

IV. Provider business mailing address

1430 HAINES AVE SUITE 108
RAPID CITY SD
57701-0689
US

V. Phone/Fax

Practice location:
  • Phone: 605-923-6573
  • Fax: 605-385-2030
Mailing address:
  • Phone: 605-923-6573
  • Fax: 605-385-2030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904006244
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2352
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: