Provider Demographics
NPI:1912660697
Name:ELLIS, LILY RENEE
Entity Type:Individual
Prefix:
First Name:LILY
Middle Name:RENEE
Last Name:ELLIS
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 1:865 MARINA BAY PKWY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-6495
Mailing Address - Country:US
Mailing Address - Phone:510-422-6311
Mailing Address - Fax:
Practice Address - Street 1:1200 CONCORD AVE STE 100
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-4969
Practice Address - Country:US
Practice Address - Phone:510-268-8120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-19
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst