Provider Demographics
NPI:1861812877
Name:ELLIS, NICOLE
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4492 ILLINOIS ST APT D
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-4390
Mailing Address - Country:US
Mailing Address - Phone:818-919-9579
Mailing Address - Fax:
Practice Address - Street 1:545 LAUREL ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-1634
Practice Address - Country:US
Practice Address - Phone:818-919-9579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-17
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health