Provider Demographics
NPI:1700364361
Name:ELLIS, MARIAH ALYSS
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:ALYSS
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7711 MCLAREN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91304-3632
Mailing Address - Country:US
Mailing Address - Phone:818-282-4130
Mailing Address - Fax:
Practice Address - Street 1:535 S MESA HILLS DR APT 711
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-5674
Practice Address - Country:US
Practice Address - Phone:818-282-4130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-04
Last Update Date:2018-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician