Provider Demographics
NPI:1083837504
Name:ELLISON, WENDY MAUREEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:WENDY
Middle Name:MAUREEN
Last Name:ELLISON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 SHEFFIELD DR
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-6648
Mailing Address - Country:US
Mailing Address - Phone:925-858-1648
Mailing Address - Fax:925-455-4373
Practice Address - Street 1:1781 BARCELONA ST
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94550-6403
Practice Address - Country:US
Practice Address - Phone:925-858-1648
Practice Address - Fax:925-455-4373
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8739103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist