MEDICARE: MRS. TENISHA HARRELL ELLIS MSW, ASW #76509

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	1041C0700X	Clinical Social Worker	76509	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	76509	OTHER	CA	ASW #

General Provider Information

NPI Number	:	1962924746
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TENISHA HARRELL ELLIS MSW, ASW #76509

Provider Business Mailing Address
First Line	:	1510 FASHION ISLAND BLVD.
Second Line	:	SUITE 110
City	:	FOSTER CITY
State	:	CA
Zip	:	94404
Country	:	US
Telephone Number	:	650-570-7273
Fax Number	:	650-570-4283

Provider Business Practice Location Address
First Line	:	1510 FASHION ISLAND BLVD STE 110
Second Line	:
City	:	FOSTER CITY
State	:	CA
Zip	:	94404-5043
Country	:	US
Telephone Number	:	650-570-7273
Fax Number	:	650-570-4283

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

Provider Enumeration Date	:	07/12/2017
Last Update Date	:	07/21/2022

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