Provider Demographics
NPI:1063543247
Name:ELLIS, RON RAY (PH D)
Entity type:Individual
Prefix:DR
First Name:RON
Middle Name:RAY
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 GLADWIN DR
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-6349
Mailing Address - Country:US
Mailing Address - Phone:925-947-2648
Mailing Address - Fax:
Practice Address - Street 1:1756 LACASSIE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-7098
Practice Address - Country:US
Practice Address - Phone:925-943-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5702103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL57020Medicare ID - Type Unspecified