Provider Demographics
NPI:1891266276
Name:ELLIS, ALYSSA JORDAN
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:JORDAN
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 1:535 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-1630
Mailing Address - Country:US
Mailing Address - Phone:209-752-8114
Mailing Address - Fax:
Practice Address - Street 1:5375 RENO CORPORATE DR
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-2381
Practice Address - Country:US
Practice Address - Phone:775-376-9426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician