=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265084461
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY ELLIS LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2019
-----------------------------------------------------
Last Update Date | 02/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 255 LOW ST STE 302
-----------------------------------------------------
City | NEWBURYPORT
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01950-3596
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-222-3121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31 NANCY LN
-----------------------------------------------------
City | RAYMOND
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03077-1839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-752-6455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------