Provider Demographics
NPI:1356828529
Name:ELLIS, ROBERTA
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N MORAIN ST STE 1250
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-2967
Mailing Address - Country:US
Mailing Address - Phone:509-783-0500
Mailing Address - Fax:509-783-9129
Practice Address - Street 1:500 N MORAIN ST STE 1250
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-2967
Practice Address - Country:US
Practice Address - Phone:509-783-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health