Provider Demographics
NPI:1114388279
Name:YEAGLE, ELLEN (PSYD, LMHC)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:
Last Name:YEAGLE
Suffix:
Gender:F
Credentials:PSYD, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 SWEETWATER LN APT 313
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-7125
Mailing Address - Country:US
Mailing Address - Phone:609-529-5815
Mailing Address - Fax:
Practice Address - Street 1:3640 N FEDERAL HWY STE B3
Practice Address - Street 2:#128
Practice Address - City:LIGHTHOUSE POINT
Practice Address - State:FL
Practice Address - Zip Code:33064-6648
Practice Address - Country:US
Practice Address - Phone:609-529-5815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPMH 1251101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health