Provider Demographics
NPI:1619182896
Name:ELLIS, NANCY LOUISE (MFT)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:LOUISE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 ANTELO VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1608
Mailing Address - Country:US
Mailing Address - Phone:310-471-1181
Mailing Address - Fax:
Practice Address - Street 1:2035 WESTWOOD BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6332
Practice Address - Country:US
Practice Address - Phone:310-444-0099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37406106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist