Provider Demographics
NPI:1851527451
Name:ELLIS, LISA PERRY (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:PERRY
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 VICENTE ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94116-2923
Mailing Address - Country:US
Mailing Address - Phone:415-307-5382
Mailing Address - Fax:
Practice Address - Street 1:1801 VICENTE ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94116-2923
Practice Address - Country:US
Practice Address - Phone:415-307-5382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-09
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS11697101YM0800X
CA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1851527451OtherBEHAVIORAL HEALTH AND SS PROVIDERS