Provider Demographics
NPI:1093043754
Name:ELLIS, DAVID T (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:T
Last Name:ELLIS
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 1:211 HUNTER PARK
Mailing Address - Street 2:LAUREL RIDGE PSYCHOLOGICAL ASSOCIATES
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740
Mailing Address - Country:US
Mailing Address - Phone:304-487-6121
Mailing Address - Fax:304-487-8741
Practice Address - Street 1:211 HUNTER PARK
Practice Address - Street 2:LAUREL RIDGE PSYCHOLOGICAL ASSOCIATES
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740
Practice Address - Country:US
Practice Address - Phone:304-487-6121
Practice Address - Fax:304-487-8741
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-18
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV988103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic