MEDICARE: DR. ELLEN SHUSTOROVICH PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	020508	NY

General Provider Information

NPI Number	:	1134546633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLEN SHUSTOROVICH PH.D.

Provider Business Mailing Address
First Line	:	1513 SOUTH AVE
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14620-2926
Country	:	US
Telephone Number	:	585-612-1016
Fax Number	:

Provider Business Practice Location Address
First Line	:	1513 SOUTH AVE
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14620-2926
Country	:	US
Telephone Number	:	585-612-1016
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2014
Last Update Date	:	08/07/2014

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