=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861938730
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LISA ELLIS PSY.D
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2017
-----------------------------------------------------
Last Update Date | 01/16/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4949 LIBERTY LN SUITE 5
-----------------------------------------------------
City | ALLENTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18106-9014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-838-5855
-----------------------------------------------------
Fax | 610-820-6308
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4949 LIBERTY LN SUITE 5
-----------------------------------------------------
City | ALLENTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18106-9014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-838-5855
-----------------------------------------------------
Fax | 610-820-6308
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST/MANAGER
-----------------------------------------------------
Name | LISA ELLIS
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 484-838-5855
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PS016670
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------