Provider Demographics
NPI:1316344948
Name:ELLISON, BEVERLY (MSW, LCSW 75361, CST)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:ELLISON
Suffix:
Gender:F
Credentials:MSW, LCSW 75361, CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:584 CASTRO ST # 2094
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-2512
Mailing Address - Country:US
Mailing Address - Phone:415-969-6886
Mailing Address - Fax:
Practice Address - Street 1:1485 WALLER STREET APT 203
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117
Practice Address - Country:US
Practice Address - Phone:415-969-6886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 104100000X
CA75361101Y00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker