Provider Demographics
NPI:1568918258
Name:ELLIS, BRENDAN TODD (MFT)
Entity Type:Individual
Prefix:MR
First Name:BRENDAN
Middle Name:TODD
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4950 HAMILTON AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95130-1750
Mailing Address - Country:US
Mailing Address - Phone:408-623-7055
Mailing Address - Fax:408-465-5341
Practice Address - Street 1:4950 HAMILTON AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95130-1750
Practice Address - Country:US
Practice Address - Phone:408-623-7055
Practice Address - Fax:408-350-2015
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPCCI 619101YP2500X
CA102547106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional