MEDICARE: MRS. MELINDA R ELLIS M.S.W. L.C.S.W.

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	2004030680	MO

General Provider Information

NPI Number	:	1326240920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MELINDA R ELLIS M.S.W. L.C.S.W.

Provider Business Mailing Address
First Line	:	1722 SOUTH GLENSTONE
Second Line	:	SUITE H
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-1513
Country	:	US
Telephone Number	:	417-881-9518
Fax Number	:	417-887-2051

Provider Business Practice Location Address
First Line	:	1722 SOUTH GLENSTONE
Second Line	:	SUITE H
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-1513
Country	:	US
Telephone Number	:	417-881-9518
Fax Number	:	417-887-2051

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

Provider Enumeration Date	:	06/05/2007
Last Update Date	:	07/08/2007

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