Provider Demographics
NPI:1649708355
Name:ELLIS, DOCK PHILLIP III
Entity type:Individual
Prefix:MRS
First Name:DOCK
Middle Name:PHILLIP
Last Name:ELLIS
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28175 ALTON WAY
Mailing Address - Street 2:
Mailing Address - City:CASTAIC
Mailing Address - State:CA
Mailing Address - Zip Code:91384-3801
Mailing Address - Country:US
Mailing Address - Phone:310-740-1353
Mailing Address - Fax:
Practice Address - Street 1:16500 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2011
Practice Address - Country:US
Practice Address - Phone:818-788-1003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician