Healthcare Provider Details

I. General information

NPI: 1356916571
Provider Name (Legal Business Name): ELLIS PSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2021
Last Update Date: 05/20/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1819 SAN ANDRO ST
TORRANCE CA
90501
US

IV. Provider business mailing address

3705 W PICO BLVD # 835
LOS ANGELES CA
90019-3451
US

V. Phone/Fax

Practice location:
  • Phone: 323-432-0389
  • Fax:
Mailing address:
  • Phone: 323-432-0389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. TIERRA T. ELLIS
Title or Position: PSYCHOLOGIST
Credential: PH.D.
Phone: 323-432-0389