Provider Demographics
NPI:1043683485
Name:ELLISON, CORWYN
Entity type:Individual
Prefix:
First Name:CORWYN
Middle Name:
Last Name:ELLISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10224 NE TORVANGER RD
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-4178
Mailing Address - Country:US
Mailing Address - Phone:206-617-2299
Mailing Address - Fax:
Practice Address - Street 1:3214 W MCGRAW ST
Practice Address - Street 2:STE 212
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98199-3239
Practice Address - Country:US
Practice Address - Phone:206-453-4882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-06
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60614988106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician