Basic Information
| Provider Information | |||||||||
| NPI: | 1760991715 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | MONICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ELLIS | ||||||||
| OtherFirstName: | MONICA | ||||||||
| OtherMiddleName: | STACEY | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NONE | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10451 MILL RUN CIR STE 400 | ||||||||
| Address2: | |||||||||
| City: | OWINGS MILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211175594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4432503471 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1900 N HOWARD ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212185909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434386742 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2017 | ||||||||
| LastUpdateDate: | 05/23/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 17041 | MD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.