Provider Demographics
NPI:1053793216
Name:KELLY A. ELLIS
Entity type:Organization
Organization Name:KELLY A. ELLIS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:760-832-4904
Mailing Address - Street 1:PO BOX 2805
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1099
Mailing Address - Country:US
Mailing Address - Phone:760-832-4904
Mailing Address - Fax:760-300-4060
Practice Address - Street 1:39760 BLACK MESA LN
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-1501
Practice Address - Country:US
Practice Address - Phone:760-832-4904
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-24
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA166861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ28136ZOtherMEDICARE PTAN
CAZZZ28136ZOtherMEDICARE PTAN