Basic Information
| Provider Information | |||||||||
| NPI: | 1578874772 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | QUINITA | ||||||||
| MiddleName: | LACHELLE | ||||||||
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| Credential: | BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1431 EDWARDS AVE | ||||||||
| Address2: | |||||||||
| City: | FIRCREST | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984666640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537786601 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1201 PACIFIC AVE | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984024301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537786601 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2010 | ||||||||
| LastUpdateDate: | 04/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | CG60146056 | WA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | LH60551573 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.