Provider Demographics
NPI:1013272343
Name:ELLIS, LOUISA CARNS (LCSW)
Entity type:Individual
Prefix:MS
First Name:LOUISA
Middle Name:CARNS
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 1:1550 CAMELOT CIR
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-7703
Mailing Address - Country:US
Mailing Address - Phone:508-725-0125
Mailing Address - Fax:508-725-0125
Practice Address - Street 1:1550 CAMELOT CIR
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-7703
Practice Address - Country:US
Practice Address - Phone:508-725-0125
Practice Address - Fax:508-725-0125
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0044411041C0700X
MA10219681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical