=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336401710
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK DALTON ELLIS LMSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2012
-----------------------------------------------------
Last Update Date | 12/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1418 FILLMORE ST
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301-3380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-735-2237
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1418 FILLMORE ST
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301-3380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-735-2237
-----------------------------------------------------
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 | LCSW-32484
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------