MEDICARE: MS. KATHRYN GAIL ELLIS MSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	000180	MO

General Provider Information

NPI Number	:	1245397256
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KATHRYN GAIL ELLIS MSW

Provider Business Mailing Address
First Line	:	3701 S LINDBERGH BLVD STE 205
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63127-1372
Country	:	US
Telephone Number	:	314-965-1942
Fax Number	:	314-835-1580

Provider Business Practice Location Address
First Line	:	3701 S LINDBERGH BLVD STE 205
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63127-1372
Country	:	US
Telephone Number	:	314-965-1942
Fax Number	:	314-835-1580

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	07/08/2007

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