Basic Information
| Provider Information | |||||||||
| NPI: | 1649463191 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLINGSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 730 SUNRISE AVENUE | ||||||||
| Address2: | BUILDING 200, STE-201 | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167823737 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 730 SUNRISE AVENUE | ||||||||
| Address2: | BUILDING 200, STE-201 | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167823737 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2007 | ||||||||
| LastUpdateDate: | 05/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YA0400X | 90183 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.