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General NPI Number Information
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NPI Number | 1811249048
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Entity Type | Individual
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Provider Name | CRYSTAL DAWN ELLIS LSCSW
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Gender | Female
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Dates
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Enumeration Date | 10/11/2012
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Last Update Date | 08/27/2024
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Provider Practice Location Address
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Address Line | 5399 HWY 43 BLDG B
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City | JOPLIN
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State | MO
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Zip | 64804-4927
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Country | US
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Telephone | 913-444-9756
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Fax |
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Provider Business Mailing Address
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Address Line | 5399 HWY 43 BLDG B
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City | JOPLIN
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State | MO
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Zip | 64804-4927
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Country | US
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Telephone | 913-444-9756
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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 | 21113
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 2022021360
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License Number State | MO
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 4761
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License Number State | KS
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