Provider Demographics
NPI:1649395385
Name:VARGAS, ELLEN TRACY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:TRACY
Last Name:VARGAS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:ELLEN
Other - Middle Name:TRACY
Other - Last Name:ARGILLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:2421 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94710-2430
Mailing Address - Country:US
Mailing Address - Phone:510-859-3781
Mailing Address - Fax:
Practice Address - Street 1:2421 4TH ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94710-2430
Practice Address - Country:US
Practice Address - Phone:510-859-3781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA262331041C0700X
NY073326-11041C0700X
CALCSW262331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical