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General NPI Number Information
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NPI Number | 1912537200
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Entity Type | Organization
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Legal Business Name | DR. STACY ELLIS, P.C.
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Dates
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Enumeration Date | 01/25/2020
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Last Update Date | 01/25/2020
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Provider Practice Location Address
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Address Line | 1900 OGDEN AVE STE 106
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City | AURORA
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State | IL
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Zip | 60504-4284
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Country | US
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Telephone | 630-405-7265
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 398
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City | WINFIELD
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State | IL
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Zip | 60190-0398
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Country | US
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Telephone | 323-228-7746
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Fax |
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Authorized Official
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Title or Position | LICENSED CLINICAL PSYCHOLOGIST
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Name | DR. STACY ELLIS
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Credential | PH. D.
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Telephone | 323-228-7746
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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