Provider Demographics
NPI:1306502463
Name:ELLISON, KERA MARIE (MED PPS)
Entity type:Individual
Prefix:
First Name:KERA
Middle Name:MARIE
Last Name:ELLISON
Suffix:
Gender:F
Credentials:MED PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 W CARSON ST
Mailing Address - Street 2:N-33
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2006
Mailing Address - Country:US
Mailing Address - Phone:310-222-5410
Mailing Address - Fax:310-787-7742
Practice Address - Street 1:1124 W CARSON ST
Practice Address - Street 2:N-33
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2006
Practice Address - Country:US
Practice Address - Phone:310-222-5410
Practice Address - Fax:310-787-7742
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1449521121101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)