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General NPI Number Information
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NPI Number | 1114437399
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Entity Type | Organization
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Legal Business Name | ELLIS CLINICAL SERVICES LLC
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Dates
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Enumeration Date | 10/02/2017
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Last Update Date | 05/13/2018
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Provider Practice Location Address
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Address Line | 2635 S WABASH AVE FL 3
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City | CHICAGO
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State | IL
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Zip | 60616
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Country | US
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Telephone | 773-377-6141
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 361
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City | BERWYN
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State | IL
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Zip | 60402-0361
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Country | US
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Telephone | 773-377-6141
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | NICOLA ELLIS
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Credential | LCSW
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Telephone | 773-793-7147
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C008340
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149018206
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License Number State | IL
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