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General NPI Number Information
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NPI Number | 1114002581
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Entity Type | Organization
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Legal Business Name | CARL R. ELLIS
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Dates
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Enumeration Date | 10/26/2006
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Last Update Date | 09/04/2012
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Provider Practice Location Address
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Address Line | 1020 INDEPENDENCE BLVD SUITE 204
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City | VIRGINIA BEACH
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State | VA
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Zip | 23455-5500
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Country | US
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Telephone | 757-640-1882
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Fax | 757-640-0253
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Provider Business Mailing Address
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Address Line | 1020 INDEPENDENCE BLVD SUITE 204
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City | VIRGINIA BEACH
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State | VA
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Zip | 23455-5500
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Country | US
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Telephone | 757-640-1882
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Fax | 757-640-0253
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Authorized Official
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Title or Position | OWNER
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Name | DR. CARL RICHARD ELLIS
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Credential | ED.D.
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Telephone | 757-640-1882
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | 0810001913
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License Number State | VA
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