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General NPI Number Information
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NPI Number | 1992063184
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Entity Type | Individual
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Provider Name | LAWRENCE CHRISTIAN ELLEDGE PH.D.
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Gender | Male
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Dates
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Enumeration Date | 04/25/2012
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Last Update Date | 12/06/2013
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Provider Practice Location Address
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Address Line | UNIVERSITY OF TENNESSEE 1404 CIRCLE DRIVE, AUSTIN PEAY, 301F
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City | KNOXVILLE
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State | TN
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Zip | 37996-4503
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Country | US
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Telephone | 865-974-1958
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Fax |
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Provider Business Mailing Address
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Address Line | UNIVERSITY OF TENNESSEE 1404 CIRCLE DRIVE, AUSTIN PEAY, 301F
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City | KNOXVILLE
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State | TN
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Zip | 37996-4503
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Country | US
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Telephone | 865-974-1958
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | T-LP1978
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License Number State | KS
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Taxonomy #2
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | T-LP1978
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License Number State | KS
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