Doctor Name: | MR. RANDY WAYNE ELLIS |
NPI Number: | 1174605125 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | |
License Number: | |
Business Practice Address: | 1445 Vista Way Red Bluff, CA - 96080 |
Business Phone Number: | 5305295819 |
Business Fax Number: | 5305294002 |
Mailing Address: | 555 Hunt House, RED BLUFF |
State: | CA |
Postal Code: | 96080 |
Phone Number: | 5308400233 |
Fax Number: | |
NPI Enumeration Date: | 10/19/2006 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YM0800X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Mental Health |
Taxonomy Definition: |