Provider Demographics
NPI:1033775382
Name:ELLMAN, BRUCE (PSYD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:ELLMAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N CAMDEN DR STE 106
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4436
Mailing Address - Country:US
Mailing Address - Phone:323-819-9991
Mailing Address - Fax:
Practice Address - Street 1:415 N CAMDEN DR STE 106
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4436
Practice Address - Country:US
Practice Address - Phone:323-819-9991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21012103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist