Provider Demographics
NPI:1053451476
Name:ELLIS, DAVID WELFORD (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WELFORD
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 ROUTE 45
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:NJ
Mailing Address - Zip Code:08079-2045
Mailing Address - Country:US
Mailing Address - Phone:856-878-0800
Mailing Address - Fax:856-878-0800
Practice Address - Street 1:325 ROUTE 45
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:NJ
Practice Address - Zip Code:08079-2045
Practice Address - Country:US
Practice Address - Phone:856-878-0800
Practice Address - Fax:856-878-0800
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJSI01417103G00000X, 103TC2200X, 103TR0400X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
052540Medicare ID - Type UnspecifiedMEDICARE IDENTIFICATION