Basic Information
| Provider Information | |||||||||
| NPI: | 1417144767 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | ELIAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 161 W VICTORIA ST | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908052175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232425000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14659 OLIVE VIEW DR | ||||||||
| Address2: | |||||||||
| City: | SYLMAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913421652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8184850888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2007 | ||||||||
| LastUpdateDate: | 04/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 33763 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 85301 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.