Healthcare Provider Details

I. General information

NPI: 1790845816
Provider Name (Legal Business Name): LAUREL RIDGE PSYCHOLOGICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 03/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 HUNTER PARK LAUREL RIDGE PSYCHOLOGICAL ASSOCIATES
PRINCETON WV
24740
US

IV. Provider business mailing address

211 HUNTER PARK LAUREL RIDGE PSYCHOLOGICAL ASSOCIATES
PRINCETON WV
24740
US

V. Phone/Fax

Practice location:
  • Phone: 304-487-6121
  • Fax: 304-487-8741
Mailing address:
  • Phone: 304-487-6121
  • Fax: 304-487-8741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number988
License Number StateWV

VIII. Authorized Official

Name: DR. DAVID T ELLIS
Title or Position: PSYCHOLOGIST/PARTNER
Credential: PSY.D.
Phone: 304-487-6121