Provider Demographics
NPI:1548976202
Name:ELLIS, ANGELA LUANA (LMSW)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:LUANA
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:LUANA
Other - Last Name:NEUMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:450 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2048
Mailing Address - Country:US
Mailing Address - Phone:208-359-7689
Mailing Address - Fax:208-488-4265
Practice Address - Street 1:450 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2048
Practice Address - Country:US
Practice Address - Phone:208-359-7689
Practice Address - Fax:208-488-4265
Is Sole Proprietor?:No
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-41785104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker