Healthcare Provider Details

I. General information

NPI: 1164332201
Provider Name (Legal Business Name): EVAN EUGENE ELLIS PCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 SE MILWAUKIE AVE APT 401
PORTLAND OR
97202-6171
US

IV. Provider business mailing address

7400 SE MILWAUKIE AVE APT 401
PORTLAND OR
97202-6171
US

V. Phone/Fax

Practice location:
  • Phone: 562-972-0911
  • Fax:
Mailing address:
  • Phone: 562-972-0911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR10040
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: