MEDICARE: DR. ELLEN R VAN ECK PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist	21511	CA
2	103TC0700X	Clinical Psychologist	21511	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	21511	OTHER	CA	LICENSE

General Provider Information

NPI Number	:	1528259553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLEN R VAN ECK PHD

Provider Business Mailing Address
First Line	:	5015 BIRCH STREET
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-2162
Country	:	US
Telephone Number	:	949-887-4166
Fax Number	:

Provider Business Practice Location Address
First Line	:	5015 BIRCH STREET
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-2162
Country	:	US
Telephone Number	:	949-887-4166
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/06/2007
Last Update Date	:	09/05/2019

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