1326630203 NPI number — STEPHANIE ELLIS, LICENSED CLINICAL SOCIAL WORKER, P.C.

Table of content: (NPI 1326630203)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326630203 NPI number — STEPHANIE ELLIS, LICENSED CLINICAL SOCIAL WORKER, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEPHANIE ELLIS, LICENSED CLINICAL SOCIAL WORKER, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326630203
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29910 MURRIETA HOT SPRINGS RD STE G304
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MURRIETA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92563-3814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-246-6152
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30290 BUCCANEER BAY UNIT D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MURRIETA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92563-8812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-246-6152
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/11/2021

Additional Information

Authorized Official

Authorized Official Last Name:
ELLIS
Authorized Official First Name:
DANA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
951-246-6152

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1730625294 . This is a "NPPES" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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