Provider Demographics
NPI:1700275625
Name:VERNON, ELLIS III (LCSW)
Entity type:Individual
Prefix:
First Name:ELLIS
Middle Name:
Last Name:VERNON
Suffix:III
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 W. EL SEGUNDO BLVD
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250
Mailing Address - Country:US
Mailing Address - Phone:310-756-3638
Mailing Address - Fax:
Practice Address - Street 1:2311 W. EL SEGUNDO BLVD
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250
Practice Address - Country:US
Practice Address - Phone:323-241-6733
Practice Address - Fax:323-756-1163
Is Sole Proprietor?:No
Enumeration Date:2015-01-15
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW595081041C0700X
CALCSW825661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical