Healthcare Provider Details

I. General information

NPI: 1740111574
Provider Name (Legal Business Name): CAMILLE ROSE ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1761 3RD ST STE 106
NORCO CA
92860-2679
US

IV. Provider business mailing address

414 E SAN BERNARDINO RD
COVINA CA
91723-1704
US

V. Phone/Fax

Practice location:
  • Phone: 626-536-4834
  • Fax:
Mailing address:
  • Phone: 626-367-3206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number39762
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: