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General NPI Number Information
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NPI Number | 1548653421
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Entity Type | Individual
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Provider Name | IVY LYNN ELLIS L.C.S.W.
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Gender | Female
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Dates
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Enumeration Date | 03/16/2015
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Last Update Date | 06/25/2019
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Provider Practice Location Address
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Address Line | 1601 SHERMAN AVE STE 510
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City | EVANSTON
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State | IL
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Zip | 60201
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Country | US
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Telephone | 847-565-8083
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Fax |
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Provider Business Mailing Address
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Address Line | 1560 N SANDBURG TER APT 2801
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City | CHICAGO
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State | IL
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Zip | 60610-7725
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Country | US
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Telephone | 847-565-8083
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 149.016923
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License Number State | IL
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