Provider Demographics
NPI:1710113980
Name:ELLIS, KATHY JEAN (LMFT)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:JEAN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12036 NEVADA CITY HWY
Mailing Address - Street 2:#237
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-8461
Mailing Address - Country:US
Mailing Address - Phone:530-477-7016
Mailing Address - Fax:530-477-5919
Practice Address - Street 1:2059 NEVADA CITY HWY
Practice Address - Street 2:SUITE 104
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-7711
Practice Address - Country:US
Practice Address - Phone:530-477-7016
Practice Address - Fax:530-477-5919
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC22869106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist