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General NPI Number Information
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NPI Number | 1548674203
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Entity Type | Organization
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Legal Business Name | ELLIS THERAPY & FITNESS
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Dates
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Enumeration Date | 06/19/2014
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Last Update Date | 06/19/2014
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Provider Practice Location Address
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Address Line | 16595 W EASTON AVE
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City | PRAIRIE VIEW
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State | IL
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Zip | 60069-2744
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Country | US
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Telephone | 847-242-1669
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Fax | 815-524-2271
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Provider Business Mailing Address
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Address Line | 16595 W EASTON AVE
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City | PRAIRIE VIEW
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State | IL
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Zip | 60069-2744
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Country | US
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Telephone | 847-242-1669
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Fax | 815-524-2271
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Authorized Official
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Title or Position | LICENSED CLINICAL SOCIAL WORKER
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Name | MRS. DEBRA ELLIS
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Credential | LCSW
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Telephone | 847-242-1669
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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 | 149013439
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License Number State | IL
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