Provider Demographics
NPI:1578874772
Name:ELLIS, QUINITA LACHELLE (BA)
Entity Type:Individual
Prefix:
First Name:QUINITA
Middle Name:LACHELLE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 EDWARDS AVE
Mailing Address - Street 2:
Mailing Address - City:FIRCREST
Mailing Address - State:WA
Mailing Address - Zip Code:98466-6640
Mailing Address - Country:US
Mailing Address - Phone:253-778-6601
Mailing Address - Fax:
Practice Address - Street 1:1201 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-4301
Practice Address - Country:US
Practice Address - Phone:253-778-6601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-23
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60146056101YM0800X
WALH60551573101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health