Healthcare Provider Details

I. General information

NPI: 1538310180
Provider Name (Legal Business Name): TRACI ELLERSHAW LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2008
Last Update Date: 10/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15285 WATERTOWN PLANK RD
ELM GROVE WI
53122-2339
US

IV. Provider business mailing address

7330 W LAYTON AVE
MILWAUKEE WI
53220-3849
US

V. Phone/Fax

Practice location:
  • Phone: 262-797-2818
  • Fax: 262-797-2814
Mailing address:
  • Phone: 414-817-8896
  • Fax: 414-817-8940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1964-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: