Provider Demographics
NPI:1316627326
Name:ELLISON, ERICKA MARIE I
Entity type:Individual
Prefix:
First Name:ERICKA
Middle Name:MARIE
Last Name:ELLISON
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3610 GLENRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-4639
Mailing Address - Country:US
Mailing Address - Phone:818-631-3547
Mailing Address - Fax:
Practice Address - Street 1:17075 DEVONSHIRE ST STE 204
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-5408
Practice Address - Country:US
Practice Address - Phone:661-373-6735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA950295232084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry