Healthcare Provider Details

I. General information

NPI: 1609227271
Provider Name (Legal Business Name): DEMATRA ELLISON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2016
Last Update Date: 06/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 EVANS AVE
SAN FRANCISCO CA
94124-1705
US

IV. Provider business mailing address

755 S VAN NESS AVE
SAN FRANCISCO CA
94110-1908
US

V. Phone/Fax

Practice location:
  • Phone: 415-920-7702
  • Fax:
Mailing address:
  • Phone: 415-642-4503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: