Individual
SUE ELLISON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
109 CHURCH ST, O FALLON, MO 63366-2894
(314) 540-1759
Mailing address
512 OAKTON RIDGE COURT, BALLWIN, MO 63021
(314) 540-1759
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
001590
MO
Other
Enumeration date
09/18/2012
Last updated
09/18/2012
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