=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477055390
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEX DS ELLIS MFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2018
-----------------------------------------------------
Last Update Date | 07/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 129 EAST LINE ST
-----------------------------------------------------
City | BISHOP
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-937-0711
-----------------------------------------------------
Fax | 760-872-4191
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1554
-----------------------------------------------------
City | BISHOP
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-937-0711
-----------------------------------------------------
Fax | 760-872-4191
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 27998
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------