Healthcare Provider Details

I. General information

NPI: 1942709191
Provider Name (Legal Business Name): JAMES RANDALL ELLIS MA, LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2018
Last Update Date: 11/07/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 N COOK ST STE 900
SPOKANE WA
99207-5879
US

IV. Provider business mailing address

PO BOX 190
TOPPENISH WA
98948-0190
US

V. Phone/Fax

Practice location:
  • Phone: 509-483-3427
  • Fax: 509-482-4040
Mailing address:
  • Phone: 509-865-2395
  • Fax: 509-865-0757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH61039976
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: