Provider Demographics
NPI:1326630203
Name:STEPHANIE ELLIS, LICENSED CLINICAL SOCIAL WORKER, P.C.
Entity Type:Organization
Organization Name:STEPHANIE ELLIS, LICENSED CLINICAL SOCIAL WORKER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:D
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:951-246-6152
Mailing Address - Street 1:29910 MURRIETA HOT SPRINGS RD STE G304
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-3814
Mailing Address - Country:US
Mailing Address - Phone:951-246-6152
Mailing Address - Fax:
Practice Address - Street 1:30290 BUCCANEER BAY UNIT D
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-8812
Practice Address - Country:US
Practice Address - Phone:951-246-6152
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1730625294OtherNPPES