MEDICARE: CHIQUITA ELLERBE MSW, LCSW-A

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	P020576	NC

General Provider Information

NPI Number	:	1376362293
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHIQUITA ELLERBE MSW, LCSW-A

Provider Business Mailing Address
First Line	:	650 HIGHLAND AVE
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27101-4362
Country	:	US
Telephone Number	:	336-607-8523
Fax Number	:

Provider Business Practice Location Address
First Line	:	650 HIGHLAND AVE
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27101-4362
Country	:	US
Telephone Number	:	336-607-8523
Fax Number	:

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

Provider Enumeration Date	:	10/08/2024
Last Update Date	:	10/14/2024

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