Provider Demographics
NPI:1457791006
Name:CHEN, ELLENA FICKETT
Entity Type:Individual
Prefix:
First Name:ELLENA
Middle Name:FICKETT
Last Name:CHEN
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 1:700 YGNACIO VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-3849
Mailing Address - Country:US
Mailing Address - Phone:925-939-7500
Mailing Address - Fax:925-939-7500
Practice Address - Street 1:700 YGNACIO VALLEY RD STE 320
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-3838
Practice Address - Country:US
Practice Address - Phone:925-939-7500
Practice Address - Fax:925-939-7500
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-27
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY31146103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8121Medicaid