Provider Demographics
NPI:1063716058
Name:ELLIS, KATHERINE DOROTHY (PHD, MSED)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:DOROTHY
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PHD, MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-6207
Mailing Address - Country:US
Mailing Address - Phone:888-497-1314
Mailing Address - Fax:888-497-1314
Practice Address - Street 1:2801 4TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103
Practice Address - Country:US
Practice Address - Phone:888-497-1314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-05
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24263103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical