Provider Demographics
NPI:1013488238
Name:ELLIS, CHANELLE
Entity Type:Individual
Prefix:
First Name:CHANELLE
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 1:44421 10TH ST W
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-3335
Mailing Address - Country:US
Mailing Address - Phone:818-654-3912
Mailing Address - Fax:818-241-6853
Practice Address - Street 1:44421 10TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3335
Practice Address - Country:US
Practice Address - Phone:818-654-3912
Practice Address - Fax:818-241-6853
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician