MEDICARE: DR. ERICA ELLIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY 24061	CA

General Provider Information

NPI Number	:	1063951507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERICA ELLIS

Provider Business Mailing Address
First Line	:	2717 S ROBERTSON BLVD
Second Line	:	SUITE F
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-2442
Country	:	US
Telephone Number	:	310-464-3440
Fax Number	:	310-464-3440

Provider Business Practice Location Address
First Line	:	2717 S ROBERTSON BLVD
Second Line	:	SUITE F
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-2442
Country	:	US
Telephone Number	:	310-464-3440
Fax Number	:	310-464-3440

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/16/2017
Last Update Date	:	02/16/2017

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