=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598197683
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALISSA KATHLEEN ELLSTROM LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2013
-----------------------------------------------------
Last Update Date | 07/31/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3500 ELLINGTON ST
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28211-1102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-336-7456
-----------------------------------------------------
Fax | 704-336-2423
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3500 ELLINGTON ST
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28211-1102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-336-7456
-----------------------------------------------------
Fax | 704-336-2423
-----------------------------------------------------
=====================================================
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 | C008090
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------