Provider Demographics
NPI:1962924746
Name:HARRELL ELLIS, TENISHA (MSW, ASW #76509)
Entity type:Individual
Prefix:MRS
First Name:TENISHA
Middle Name:
Last Name:HARRELL ELLIS
Suffix:
Gender:F
Credentials:MSW, ASW #76509
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 FASHION ISLAND BLVD.
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FOSTER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94404
Mailing Address - Country:US
Mailing Address - Phone:650-570-7273
Mailing Address - Fax:650-570-4283
Practice Address - Street 1:1510 FASHION ISLAND BLVD STE 110
Practice Address - Street 2:
Practice Address - City:FOSTER CITY
Practice Address - State:CA
Practice Address - Zip Code:94404-5043
Practice Address - Country:US
Practice Address - Phone:650-570-7273
Practice Address - Fax:650-570-4283
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA765091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA76509OtherASW #