Active NPI
Shannon Ellis
- Clinical Social Worker
- Columbus, MS
National Provider Identifier
1417604331
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Social Worker
- License
- C11725
- Practice address
- 75 Wood Glen LN
Columbus, MS 39705-3273 - Phone
- (662) 574-2150
- NPI assigned
- Mar 10, 2022
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | C11725 | MS | Primary |
| Clinical Social Worker | 1041C0700X | 6518C | AL |
Addresses
Primary practice location
75 Wood Glen LN
Columbus, MS 39705-3273
Mailing address
75 Wood Glen LN
Columbus, MS 39705-3273
Phone (662) 574-2150
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 6518C | AL | MD | Clinical Social Worker |
| C11725 | MS | MD | Clinical Social Worker |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1646870400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1760572800000",
"number": "1417604331",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "75 WOOD GLEN LN",
"city": "COLUMBUS",
"state": "MS",
"postal_code": "397053273",
"telephone_number": "662-574-2150"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "75 WOOD GLEN LN",
"city": "COLUMBUS",
"state": "MS",
"postal_code": "397053273",
"telephone_number": "662-574-2150"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ELLIS",
"first_name": "SHANNON",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2022-03-10",
"last_updated": "2025-10-16",
"certification_date": "2025-10-16",
"status": "A"
},
"taxonomies": [
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "MS",
"license": "C11725",
"primary": true
},
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "AL",
"license": "6518C",
"primary": false
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Columbus, MS
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 16, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.