Provider Demographics
NPI:1114002581
Name:CARL R. ELLIS
Entity Type:Organization
Organization Name:CARL R. ELLIS
Other - Org Name:SPECTRUM PSYCHOLOGICAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:757-640-1882
Mailing Address - Street 1:1020 INDEPENDENCE BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-5500
Mailing Address - Country:US
Mailing Address - Phone:757-640-1882
Mailing Address - Fax:757-640-0253
Practice Address - Street 1:1020 INDEPENDENCE BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-5500
Practice Address - Country:US
Practice Address - Phone:757-640-1882
Practice Address - Fax:757-640-0253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001913103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA260026000OtherOPTIMA HEALTH
VA007700580Medicaid
VA680001404Medicare ID - Type Unspecified