Provider Demographics
NPI:1396969069
Name:ELLIS, FORBES (MFT)
Entity type:Individual
Prefix:MR
First Name:FORBES
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 POTRERO ST
Mailing Address - Street 2:SUITE 56
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-2741
Mailing Address - Country:US
Mailing Address - Phone:831-566-2993
Mailing Address - Fax:831-566-2993
Practice Address - Street 1:303 POTRERO ST
Practice Address - Street 2:SUITE 56
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-2741
Practice Address - Country:US
Practice Address - Phone:831-566-2993
Practice Address - Fax:831-566-2993
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist