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General NPI Number Information
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NPI Number | 1568918258
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Entity Type | Individual
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Provider Name | BRENDAN TODD ELLIS MFT
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Gender | Male
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Dates
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Enumeration Date | 09/01/2016
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Last Update Date | 01/14/2019
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Provider Practice Location Address
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Address Line | 4950 HAMILTON AVE SUITE 102
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City | SAN JOSE
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State | CA
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Zip | 95130-1750
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Country | US
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Telephone | 408-623-7055
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Fax | 408-350-2015
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Provider Business Mailing Address
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Address Line | 4950 HAMILTON AVE STE 6
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City | SAN JOSE
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State | CA
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Zip | 95130-1750
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Country | US
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Telephone | 408-623-7055
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Fax | 408-465-5341
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | PCCI 619
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 102547
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License Number State | CA
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