Provider Demographics
NPI:1720558711
Name:ELLIS, WILLIAM BLAIR JR
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BLAIR
Last Name:ELLIS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W A ST
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2605
Mailing Address - Country:US
Mailing Address - Phone:509-452-1000
Mailing Address - Fax:509-452-1004
Practice Address - Street 1:611 W A ST
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-2605
Practice Address - Country:US
Practice Address - Phone:509-452-1000
Practice Address - Fax:509-452-1004
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00002864101YA0400X
WACL60157386101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)