Provider Demographics
NPI:1346476546
Name:ELLIS, DIANA A (LCSW)
Entity Type:Individual
Prefix:MS
First Name:DIANA
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 1:507 BLUEBERRY TER
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129-1902
Mailing Address - Country:US
Mailing Address - Phone:408-253-3918
Mailing Address - Fax:
Practice Address - Street 1:877 W FREMONT AVE STE K5
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-2319
Practice Address - Country:US
Practice Address - Phone:408-517-9835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS139111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical