Healthcare Provider Details

I. General information

NPI: 1013269976
Provider Name (Legal Business Name): TIERRA T. ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 05/24/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1819 SAN ARDO 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 TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: