MEDICARE: KEASHA T WALTON ELLIS PAY.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	5120	NV

General Provider Information

NPI Number	:	1720213374
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEASHA T WALTON ELLIS PAY.D

Provider Business Mailing Address
First Line	:	8455 OFFENHAUSER DR APT 1218
Second Line	:
City	:	RENO
State	:	NV
Zip	:	89511-1754
Country	:	US
Telephone Number	:	775-484-6195
Fax Number	:	916-473-5766

Provider Business Practice Location Address
First Line	:	8455 OFFENHAUSER DR APT 1218
Second Line	:
City	:	RENO
State	:	NV
Zip	:	89511
Country	:	US
Telephone Number	:	775-484-6195
Fax Number	:	916-473-5766

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2009
Last Update Date	:	05/20/2026

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