Provider Demographics
NPI:1740595768
Name:EDMUNDS, ELLIS
Entity Type:Individual
Prefix:
First Name:ELLIS
Middle Name:
Last Name:EDMUNDS
Suffix:
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 1:4243 TERRACE ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5127
Mailing Address - Country:US
Mailing Address - Phone:510-919-8366
Mailing Address - Fax:
Practice Address - Street 1:4243 TERRACE ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5127
Practice Address - Country:US
Practice Address - Phone:510-919-8366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-13
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 390200000X
CAPSY27058103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program