Provider Demographics
NPI:1417144767
Name:ELLIS, ELIAS
Entity Type:Individual
Prefix:
First Name:ELIAS
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 W VICTORIA ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-2175
Mailing Address - Country:US
Mailing Address - Phone:323-242-5000
Mailing Address - Fax:
Practice Address - Street 1:14659 OLIVE VIEW DR
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-1652
Practice Address - Country:US
Practice Address - Phone:818-485-0888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33763101YM0800X
CA853011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health