Provider Demographics
NPI:1245584473
Name:ELLIS, AMBER RAYE (CAC III)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:RAYE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:CAC III
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:RAYE
Other - Last Name:LOGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CAC III
Mailing Address - Street 1:8801 LIPAN ST
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80260-4912
Mailing Address - Country:US
Mailing Address - Phone:303-657-3700
Mailing Address - Fax:303-412-3334
Practice Address - Street 1:8801 LIPAN ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80260-4912
Practice Address - Country:US
Practice Address - Phone:303-657-3700
Practice Address - Fax:303-412-3334
Is Sole Proprietor?:No
Enumeration Date:2012-11-09
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5968101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)