MEDICARE: LISA JOANNE ELLIS

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	172V00000X	Community Health Worker
3	373H00000X	Day Training/Habilitation Specialist

General Provider Information

NPI Number	:	1194960864
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA JOANNE ELLIS

Provider Business Mailing Address
First Line	:	1300 CODDINGTOWN CTR
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95401-3537
Country	:	US
Telephone Number	:	707-565-7640
Fax Number	:

Provider Business Practice Location Address
First Line	:	2245 CHALLENGER WAY
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95407-5418
Country	:	US
Telephone Number	:	707-565-6338
Fax Number	:

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

Provider Enumeration Date	:	12/10/2008
Last Update Date	:	07/17/2025

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