Provider Demographics
NPI:1821174913
Name:ELLIS, MARCIA P (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARCIA
Middle Name:P
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4482 MARKET ST STE 408
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-7780
Mailing Address - Country:US
Mailing Address - Phone:805-656-1818
Mailing Address - Fax:805-642-5420
Practice Address - Street 1:4482 MARKET ST STE 408
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-7780
Practice Address - Country:US
Practice Address - Phone:805-656-1818
Practice Address - Fax:805-642-5420
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7283103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP7283Medicare ID - Type Unspecified