Provider Demographics
NPI:1720696743
Name:ELLIS, CHYNNA
Entity Type:Individual
Prefix:
First Name:CHYNNA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHYNNA
Other - Middle Name:
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5148 GARDEN LN APT A
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-1787
Mailing Address - Country:US
Mailing Address - Phone:702-204-4513
Mailing Address - Fax:
Practice Address - Street 1:5148 GARDEN LN APT A
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-1787
Practice Address - Country:US
Practice Address - Phone:702-204-4513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV106S00000X
106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician