Provider Demographics
NPI:1003185273
Name:ELLIS-WHITE, PRISCILLA
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:ELLIS-WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1779 ERICKSON CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-6314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8626 LOWER SACRAMENTO RD
Practice Address - Street 2:SUITE #41
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-1835
Practice Address - Country:US
Practice Address - Phone:209-478-2487
Practice Address - Fax:209-478-1476
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-18
Last Update Date:2011-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)