Provider Demographics
NPI:1528202173
Name:ELLIS, TERRANCE F
Entity Type:Individual
Prefix:
First Name:TERRANCE
Middle Name:F
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 1:41870 KALMIA ST
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-8839
Mailing Address - Country:US
Mailing Address - Phone:951-696-3501
Mailing Address - Fax:
Practice Address - Street 1:41870 KALMIA ST
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-8839
Practice Address - Country:US
Practice Address - Phone:951-696-3501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-27
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health