Provider Demographics
NPI:1619138070
Name:ELLIS, IRENE GUTIERREZ (PSYD)
Entity Type:Individual
Prefix:DR
First Name:IRENE
Middle Name:GUTIERREZ
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5700 S SICILY ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80015-4599
Mailing Address - Country:US
Mailing Address - Phone:303-883-1082
Mailing Address - Fax:720-362-2435
Practice Address - Street 1:2101 S BLACKHAWK ST., STE 240, RM 4
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-1475
Practice Address - Country:US
Practice Address - Phone:720-316-5840
Practice Address - Fax:720-362-2435
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-18
Last Update Date:2020-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3619103TC0700X
CO7827103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO61452769Medicaid