Provider Demographics
NPI:1215017009
Name:ELLIS, CHARLES (LCSW-C)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4164 BROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-3400
Mailing Address - Country:US
Mailing Address - Phone:951-683-5193
Mailing Address - Fax:
Practice Address - Street 1:4164 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3400
Practice Address - Country:US
Practice Address - Phone:951-683-5193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5980-C1041C0700X
MD269601041C0700X
CALCS 191431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1982975009Medicaid