MEDICARE: ELLEN D. STODDARD 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	PS008455L	PA
2	103TC0700X	Clinical Psychologist	PS008455L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0495987000	OTHER	PA	INDEPENDENCE BLUE CROSS
2	608672	OTHER	PA	HIGHMARK BLUE SHIELD

General Provider Information

NPI Number	:	1477768737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN D. STODDARD PH.D.

Provider Business Mailing Address
First Line	:	1455 HAMPSTEAD RD
Second Line	:
City	:	WYNNEWOOD
State	:	PA
Zip	:	19096-3105
Country	:	US
Telephone Number	:	215-545-2655
Fax Number	:

Provider Business Practice Location Address
First Line	:	1722 PINE ST
Second Line	:	1ST FLOOR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-6764
Country	:	US
Telephone Number	:	215-545-2655
Fax Number	:

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

Provider Enumeration Date	:	05/11/2007
Last Update Date	:	07/23/2007

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