Provider Demographics
NPI:1538957162
Name:BLACK, ELLIE MARIE
Entity type:Individual
Prefix:
First Name:ELLIE
Middle Name:MARIE
Last Name:BLACK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NUTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-3102
Mailing Address - Country:US
Mailing Address - Phone:229-472-7816
Mailing Address - Fax:
Practice Address - Street 1:2500 NUTWOOD AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-3102
Practice Address - Country:US
Practice Address - Phone:229-472-7816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-25
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician