Provider Demographics
NPI:1003644253
Name:ELLIS, ARIEL MADISON (LEP, MA, PPS, NCSP)
Entity type:Individual
Prefix:
First Name:ARIEL
Middle Name:MADISON
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LEP, MA, PPS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 VALLOMBROSA AVENUE PO BOX #201
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 EL CORTEZ CIR
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-1210
Practice Address - Country:US
Practice Address - Phone:530-332-8249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALEP4456103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool