Healthcare Provider Details

I. General information

NPI: 1245556893
Provider Name (Legal Business Name): COLLEEN VIOLET ELLIS MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2010
Last Update Date: 04/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 W 12TH AVE
EUGENE OR
97401
US

IV. Provider business mailing address

687 CHESHIRE AVE
EUGENE OR
97402-5060
US

V. Phone/Fax

Practice location:
  • Phone: 541-762-4334
  • Fax: 541-684-4156
Mailing address:
  • Phone: 416-844-1005
  • Fax: 541-684-4156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: