Provider Demographics
NPI:1962746859
Name:ELLIS, MAUREEN (LICSW, LCSW)
Entity type:Individual
Prefix:MS
First Name:MAUREEN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LICSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4151 THOMAS AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55412-1517
Mailing Address - Country:US
Mailing Address - Phone:612-310-8683
Mailing Address - Fax:651-925-0441
Practice Address - Street 1:4151 THOMAS AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55412
Practice Address - Country:US
Practice Address - Phone:818-209-9885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-16
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical