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NPI Code Detail

MEDICARE: DR. SUSAN G ELLIS PH.D.

MEDICARE: DR. SUSAN G ELLIS 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
1103TC0700XClinical PsychologistPY2173FL

General Provider Information

NPI Number : 1578633350
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. SUSAN G ELLIS PH.D.
Provider Business Mailing Address
First Line : 3233 E BAY DR
Second Line : SUITE 100
City : LARGO
State : FL
Zip : 33771-1900
Country : US
Telephone Number : 727-536-2200
Fax Number : 727-531-5088
Provider Business Practice Location Address
First Line : 3233 E BAY DR
Second Line : SUITE 100
City : LARGO
State : FL
Zip : 33771-1900
Country : US
Telephone Number : 727-536-2200
Fax Number : 727-531-5088
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/08/2006
Last Update Date : 07/08/2007

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