Provider Demographics
NPI:1538990999
Name:ELLIS, CRYSTAL D
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:D
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1134
Mailing Address - Street 2:
Mailing Address - City:CHELAN
Mailing Address - State:WA
Mailing Address - Zip Code:98816-1134
Mailing Address - Country:US
Mailing Address - Phone:559-250-6643
Mailing Address - Fax:
Practice Address - Street 1:430 S 2ND ST UNIT 1E
Practice Address - Street 2:
Practice Address - City:CHELAN
Practice Address - State:WA
Practice Address - Zip Code:98816-9666
Practice Address - Country:US
Practice Address - Phone:509-393-5932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60949824101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health