Provider Demographics
NPI:1174155220
Name:ELLIS, GINA L (LMP, MMT, LMT)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:L
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LMP, MMT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2228 FENTON PKWY APT 202
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4779
Mailing Address - Country:US
Mailing Address - Phone:480-245-0343
Mailing Address - Fax:
Practice Address - Street 1:2228 FENTON PKWY APT 202
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4779
Practice Address - Country:US
Practice Address - Phone:480-245-0343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35392225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist