Provider Demographics
NPI:1073548186
Name:ELLIS, KELLY A (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2805
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-2805
Mailing Address - Country:US
Mailing Address - Phone:760-832-4904
Mailing Address - Fax:
Practice Address - Street 1:39760 BLACK MESA LN
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260
Practice Address - Country:US
Practice Address - Phone:760-832-4904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 166861041C0700X
COCSW.09924161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ28136ZMedicare ID - Type Unspecified