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General NPI Number Information
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NPI Number | 1053793216
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Entity Type | Organization
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Legal Business Name | KELLY A. ELLIS
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Dates
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Enumeration Date | 06/24/2015
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Last Update Date | 08/01/2023
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Provider Practice Location Address
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Address Line | 39760 BLACK MESA LN
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City | PALM DESERT
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State | CA
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Zip | 92260-1501
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Country | US
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Telephone | 760-832-4904
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2805
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City | RANCHO MIRAGE
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State | CA
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Zip | 92270-1099
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Country | US
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Telephone | 760-832-4904
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Fax | 760-300-4060
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Authorized Official
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Title or Position | OWNER
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Name | MS. KELLY A ELLIS
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Credential | LCSW
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Telephone | 760-832-4904
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 16686
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License Number State | CA
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