Provider Demographics
NPI:1952618134
Name:ELLIS, AZELIN ANN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:AZELIN
Middle Name:ANN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 E 12TH ST
Mailing Address - Street 2:SUITE 259
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-3424
Mailing Address - Country:US
Mailing Address - Phone:510-410-7271
Mailing Address - Fax:
Practice Address - Street 1:3301 E 12TH ST
Practice Address - Street 2:SUITE 259
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-3424
Practice Address - Country:US
Practice Address - Phone:510-410-7271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-09
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26967103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist