Provider Demographics
NPI:1902125636
Name:ELLIS, TONNETTE NA
Entity Type:Individual
Prefix:
First Name:TONNETTE
Middle Name:NA
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TONI
Other - Middle Name:
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1854 HEMET ST
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583
Mailing Address - Country:US
Mailing Address - Phone:909-717-8905
Mailing Address - Fax:
Practice Address - Street 1:1854 HEMET ST
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583
Practice Address - Country:US
Practice Address - Phone:909-717-8905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-20
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health