Provider Demographics
NPI:1780090340
Name:ELLIS, DEBRA
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:LEE
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPT LIC PSYCH TECH
Mailing Address - Street 1:10910 PINE VIEW HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-2618
Mailing Address - Country:US
Mailing Address - Phone:916-390-5816
Mailing Address - Fax:
Practice Address - Street 1:7340 KILBORN DR
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-3336
Practice Address - Country:US
Practice Address - Phone:707-484-2276
Practice Address - Fax:916-974-7851
Is Sole Proprietor?:No
Enumeration Date:2014-07-03
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT18954167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician