Provider Demographics
NPI:1508424524
Name:ELLIS, TAWNEY LEE
Entity Type:Individual
Prefix:
First Name:TAWNEY
Middle Name:LEE
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 1:2586 NW PARNELL TER
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-4484
Mailing Address - Country:US
Mailing Address - Phone:307-277-1921
Mailing Address - Fax:
Practice Address - Street 1:9115 SW OLESON RD STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-6876
Practice Address - Country:US
Practice Address - Phone:971-236-0915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health