Provider Demographics
NPI:1053014647
Name:ELLEN, MARLON TERRY II
Entity type:Individual
Prefix:
First Name:MARLON
Middle Name:TERRY
Last Name:ELLEN
Suffix:II
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 1:1953 N SAGE AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-2825
Mailing Address - Country:US
Mailing Address - Phone:909-751-5521
Mailing Address - Fax:
Practice Address - Street 1:2263 DONALD ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92407-6421
Practice Address - Country:US
Practice Address - Phone:909-751-5521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician