Provider Demographics
NPI:1437659661
Name:ELLETT, CARLA JEAN
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:JEAN
Last Name:ELLETT
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 1:12559 KUMQUAT PL
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-3864
Mailing Address - Country:US
Mailing Address - Phone:909-631-8375
Mailing Address - Fax:
Practice Address - Street 1:15693 LIVE OAK RD
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-3837
Practice Address - Country:US
Practice Address - Phone:909-534-7314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst