Provider Demographics
NPI:1275720997
Name:ELLIS, THOMAS SHAWN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:SHAWN
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PSYD
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 640136
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94164-0136
Mailing Address - Country:US
Mailing Address - Phone:415-359-4586
Mailing Address - Fax:
Practice Address - Street 1:1240 CALIFORNIA ST APT 3
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-5060
Practice Address - Country:US
Practice Address - Phone:415-359-4586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23672103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical