Healthcare Provider Details

I. General information

NPI: 1780090340
Provider Name (Legal Business Name): DEBRA ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEBRA LEE ELLIS LPT LIC. PSYCH TECH

II. Dates (important events)

Enumeration Date: 07/03/2014
Last Update Date: 08/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7340 KILBORN DR
FAIR OAKS CA
95628-3336
US

IV. Provider business mailing address

10910 PINE VIEW HEIGHTS RD
NEVADA CITY CA
95959-2618
US

V. Phone/Fax

Practice location:
  • Phone: 707-484-2276
  • Fax: 916-974-7851
Mailing address:
  • Phone: 916-390-5816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT18954
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: