Provider Demographics
NPI:1063533156
Name:ELLIS, HELENE RITA (LCSW, PHD)
Entity type:Individual
Prefix:DR
First Name:HELENE
Middle Name:RITA
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LCSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 WELLINGTON CT
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4975
Mailing Address - Country:US
Mailing Address - Phone:847-475-4407
Mailing Address - Fax:847-475-4420
Practice Address - Street 1:3330 OLD GLENVIEW RD
Practice Address - Street 2:SUITE 15
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-2963
Practice Address - Country:US
Practice Address - Phone:847-800-4408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01633491OtherBLUE CROSS AND BLUE SHIEL