Provider Demographics
NPI:1700439403
Name:ELLIS, MARIAH ASHLEY (LADC, LSW)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:ASHLEY
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LADC, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:568 WESTVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-1354
Mailing Address - Country:US
Mailing Address - Phone:218-205-6483
Mailing Address - Fax:
Practice Address - Street 1:530 W FIR AVE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-1364
Practice Address - Country:US
Practice Address - Phone:218-998-8166
Practice Address - Fax:218-998-8150
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305466101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)