Provider Demographics
NPI:1366611857
Name:ELLIS, CHRISTINA L (CERTIFIED MEDIATOR)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:L
Last Name:ELLIS
Suffix:
Gender:F
Credentials:CERTIFIED MEDIATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1381
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-1381
Mailing Address - Country:US
Mailing Address - Phone:877-355-4737
Mailing Address - Fax:951-245-7036
Practice Address - Street 1:700 SOUTH PARK AVE
Practice Address - Street 2:SUITE 780
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-1546
Practice Address - Country:US
Practice Address - Phone:951-245-7036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACERTIFIED MEDIATOR101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional