Provider Demographics
NPI:1609698406
Name:ELLINGTON, TAMRA JANAE
Entity type:Individual
Prefix:
First Name:TAMRA
Middle Name:JANAE
Last Name:ELLINGTON
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 1:993 S SANTA FE AVE # 92
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-6995
Mailing Address - Country:US
Mailing Address - Phone:650-814-0465
Mailing Address - Fax:
Practice Address - Street 1:501 W BROADWAY STE 800
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-3546
Practice Address - Country:US
Practice Address - Phone:888-880-9270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-31
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician