Provider Demographics
NPI:1548674203
Name:ELLIS THERAPY & FITNESS
Entity type:Organization
Organization Name:ELLIS THERAPY & FITNESS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:847-242-1669
Mailing Address - Street 1:16595 W EASTON AVE
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE VIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60069-2744
Mailing Address - Country:US
Mailing Address - Phone:847-242-1669
Mailing Address - Fax:815-524-2271
Practice Address - Street 1:16595 W EASTON AVE
Practice Address - Street 2:
Practice Address - City:PRAIRIE VIEW
Practice Address - State:IL
Practice Address - Zip Code:60069-2744
Practice Address - Country:US
Practice Address - Phone:847-242-1669
Practice Address - Fax:815-524-2271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490134391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty