Provider Demographics
NPI:1053146068
Name:ELLIS, JOANNE EVELYN
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:EVELYN
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 1:1900 E LOS ANGELES AVE
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-6560
Mailing Address - Country:US
Mailing Address - Phone:805-573-0620
Mailing Address - Fax:
Practice Address - Street 1:1900 E LOS ANGELES AVE
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-6560
Practice Address - Country:US
Practice Address - Phone:805-537-0620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician