Provider Demographics
NPI:1366334054
Name:ELLIS, KELSEY (MA)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:X
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 FRANCES AVE
Mailing Address - Street 2:
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044-2819
Mailing Address - Country:US
Mailing Address - Phone:925-330-6574
Mailing Address - Fax:
Practice Address - Street 1:60 FRANCES AVE
Practice Address - Street 2:
Practice Address - City:PACIFICA
Practice Address - State:CA
Practice Address - Zip Code:94044-2819
Practice Address - Country:US
Practice Address - Phone:925-330-6574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-17
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator