Provider Demographics
NPI:1245891563
Name:ELLIS, EMYLIE (MSW, ACSW)
Entity type:Individual
Prefix:MISS
First Name:EMYLIE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-5622
Mailing Address - Country:US
Mailing Address - Phone:323-233-0425
Mailing Address - Fax:
Practice Address - Street 1:710 E 111TH PL
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059
Practice Address - Country:US
Practice Address - Phone:323-233-0425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical