Individual
ELLIS EDMUNDS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
4243 TERRACE ST, OAKLAND, CA 94611-5127
(510) 919-8366
Mailing address
4243 TERRACE ST, OAKLAND, CA 94611-5127
(510) 919-8366
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
—
—
103TC0700X
Clinical Psychologist
Primary
PSY27058
CA
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
08/13/2010
Last updated
07/22/2020
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