MEDICARE: DR. LAUREN M. 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
1	103TC1900X	Counseling Psychologist	019389-1	NY

General Provider Information

NPI Number	:	1669775011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAUREN M. ELLIS PH.D.

Provider Business Mailing Address
First Line	:	10 GRACE AVE
Second Line	:	OFFICE #6
City	:	GREAT NECK
State	:	NY
Zip	:	11021-2447
Country	:	US
Telephone Number	:	646-535-2641
Fax Number	:

Provider Business Practice Location Address
First Line	:	10 GRACE AVE
Second Line	:	OFFICE #6
City	:	GREAT NECK
State	:	NY
Zip	:	11021-2447
Country	:	US
Telephone Number	:	646-535-2641
Fax Number	:

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

Provider Enumeration Date	:	12/07/2010
Last Update Date	:	09/19/2012

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