Provider Demographics
NPI:1356658108
Name:ELLIS FREDERICK, CHRISTIAN DANYELL (LCSW, CCM)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:DANYELL
Last Name:ELLIS FREDERICK
Suffix:
Gender:F
Credentials:LCSW, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8105 GRASSY MEADOW CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46259-7728
Mailing Address - Country:US
Mailing Address - Phone:317-965-3349
Mailing Address - Fax:
Practice Address - Street 1:4715 VIEWRIDGE AVE STE 110
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1680
Practice Address - Country:US
Practice Address - Phone:800-257-8715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005465A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical