Healthcare Provider Details

I. General information

NPI: 1245891563
Provider Name (Legal Business Name): EMYLIE ELLIS MSW, ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 08/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 E 111TH PL
LOS ANGELES CA
90059
US

IV. Provider business mailing address

4211 AVALON BLVD
LOS ANGELES CA
90011-5622
US

V. Phone/Fax

Practice location:
  • Phone: 323-233-0425
  • Fax:
Mailing address:
  • Phone: 323-233-0425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: