Provider Demographics
NPI:1104069061
Name:ELLIS, VICKIE R (LCSW)
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:R
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2480 LLEWELLYN AVE STE 5800
Mailing Address - Street 2:
Mailing Address - City:FORT MEADE
Mailing Address - State:MD
Mailing Address - Zip Code:20755-5129
Mailing Address - Country:US
Mailing Address - Phone:301-677-8798
Mailing Address - Fax:
Practice Address - Street 1:FORT GEORGE G. MEADE, MEDDAC HEADQUARTERS
Practice Address - Street 2:2480 LLEWELLYN AVE., STE 5800
Practice Address - City:FT. MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755-5129
Practice Address - Country:US
Practice Address - Phone:301-677-8798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-08
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
09040070111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA49-45573Medicaid
VA49-45573Medicaid